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Full text of "First lines of the practice of physic (Volume 1)"

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NATIONAL LIBRARY OF MEDICINE 
Washington 




Founded 1836 



U. S. Department of Health, Education, and Welfare 

Public Health Service 



FIRST LINES 



OF THE 



PRACTICE of PHYSIC, 



~^v^*5^>?Q^^lSB^«€^«*----' 



WILLIAM CULLEN, M. D. 

Profeflbr of the Practice of Phyfic in the Univerfity of Edinburgh ; 
Firft Phylician to his Britannic Majefty for Scotland ; 
Fellow of the Royal College of Phyficians of Edinburgh ; 

Of the Royal Societies of London and of Edinburgh, 
Of the Royal Society of Medicine of Paris, &c. &c. &c; 

A NEW EDITION. 

From the Laft British Edition, 
Revised, Corrected and Enlarged, by the Author. 



IN THREE VOLUMES. 





printed at WORCESTER, Massachusetts, 
by ISAIAH THOMAS. 

Sold at his Bookstore in WORCESTER, and bv him aad 
Company in BOSTON, 

MDCCXC. 



CONTENTS. 



•"*»eoMa<»W(XOjDDKce^^ • 



Preface 


- 


Page 19 


INTRODUCTION 




49 


PART 


I. 





54 



of PYREXIA, or FEBRILE DIS- 
EASES 

BOOK I. 

of FEVERS 

CHAPTER I. 

Of the Phenomena of Fevers - 54 

CHAP. II. 

Of the Proximate Caufe of Fever - 66 

CHAP. III. 

Of the Difference of Fevers, and its 
Caufes - - .. 8 2 

CHAP, 



CONTENTS. 

CHAP. IV. 

Of the remote Caufes 0/ Fevers - 94 

CHAP. V. 

Of the Prognofis of Fevers - 109 

CHAP. VI. 

Of the Method of Cure in F 'ever s 124 

Se6t. I. Of the Cure in Continued Fe- 
vers - _ 124 
Sett. II. Of the Cure of Intermittent 
Fevers - _ 173 

BOOK II. 

of INFLAMMATIONS,orPHLEG- 
MASI.E - - 178 

CHAP. I. 

Of Inflammation in general 178 

Sett. I. Of the Phenomena of Inflam- 
mation - - - 178 
Sett. II. Of the proximate Caufe of In- 
flammation - 180 
Sett. III. Of the Terminations of In- 
flammation - - 188 
Sett. IV. Of the remote Caufes of In- 
flammation - - 197 
Sett. V. Of the Cure of Inflammation 198 

CHAP. 



CONT E N T S. 

Page. 

CHAP. II. 

Of Inflammation, more flriclly Cu- 
taneous - - - 205; 

CHAP. III. 

0/Ophthal m i a, or Inflammation of the 

Eye - - « J 209 

CHAP. IV. 

Of Phrensy, or Phrenitis - 217 

CHAP. V. 

Of the Quinsy, or Cynanche - 222: 

Se£t. 1. Of the Cynanche Tqnfillaris 222 
Seft. II. Of the Cynanche Maligna 226 
Seft. III. Of the Cynanche Trachealis 231 
Sea. IV. Of the Cynanche Pharyn- 

g<ea _ _ 237- 

Sett. V. Of the Cynanche Parotide 238 

CHAP. VI. 

Of Pneumonic Inflammation 240. 

CHAP. VII. 

Of Peripneumonia Notha.w Baf- 
tard Peripneumony - 265 . 

CHAP,. 



CONTENTS. 

Page. 

CHAP. VIII. 

Of the Gastritis, or Inflammation of 

the Stomach - - 272 

CHAP. IX. 

Of the Enteritis, or Inflammation of 
the Intejlines - - 283 

CHAP. X. 

Of the Hepatitis, or Inf animation of 
the Liver - - 286 

CHAP. XL 

Of the Nephritis, or Infammation of 
the Kidneys - - 293 

CHAP. XII. 

Of the Rheumatism - - 296 

C II A P. XIII. 

Of the Toothach, or Odontalgia 314 

C II A P. XIV. 

Of the Gout - - 323 



»9 



&$,£&^l8g. 



1 O deliver a Syltem of the Doitnnes 
and Rules proper ior directing the Praftice of Phyfic, is 
an undertaking that appears to me to be attended with 
great difficulty ; and, after an experience of more than 
forty years in that practice, as well as after much reading 
and reflection, it was with great diffidence that I ever en- 
tered upon Inch a work. It was, however, what feemed 
to be my duty as a Profeflbr that induced me to make the 
attempt ; and I was engaged in it by the fame fentiments 
that the illuftrious Dr. Boerhaave has expreffed in the 
following paflage of the Preface to his Inftitutions : Simul 
enlm docendo admotus eramfenji, propriorum cogitatorum ex~ 
plicatione docentem plus proficere, quatn fi opus ab alio con- 
fcriptum interpretari fufcipit. Sua quippe optime intelligit, 
fua cuique pra aeteris placent, unde clarior fere doclrina, at- 
que animata plerumque Jequitur oratio. Qui verofenfa alte- 
rius exponit, infelicius fapenutnero eadem ajfequitur ; quum- 
quefuo qui/que fenfu abundat, multa refutanda frequenter in- 
*venit, unde grwvemfrufira laborem aggravat, minufque in- 
citato, diclione utitur . It is well known, that a Text book 
is not only extremely ufeful, but neceffary to Students 
who are to hear Lectures j and from the fame confuta- 
tions 



20 PREFACE. 

tions that moved Dr. Boerhaave, I alfo wifhed to have one 
for my'elf ; while at the fame time, from fome peculiar 
circumftances in my fituation, I had fome additional in- 
ducements to undertake fuch a work. 

before I was eftablifhed as a Profefier of the Practice 
of Phyfic in thisUniverfity, I had been employed in giving 
Clinical Lectures in the Royal Infirmary ; and upon that 
occafion had delivered, what, in my own opinion, feemed 
molt juft with regard to both the nature and the cure of 
the difeafes of which I had occafion to treat. But I foon 
found, that my doctrines were taken notice of, as new, and 
peculiar to myfelf ; and were accordingly feverely criticif- 
ed by thofe who, having long before been trained up in the 
fyftem of Boerhaave, had continued to think that that fyf- 
tem neither required any change, nor admitted of any a- 
mendment. I found, at the fame time, that my doctrines 
were frequently criticifed by perfons who either had not 
been informed of them correclly, or who feemed not to 
understand them fully ; and therefore, as foon as I was 
employed to teach a more complete fyftem of the Prac- 
tice of Phyfic, I judged it neceflary to publifh a Text 
book, not only for the benefit of my hearers, but that I 
might alfo have an opportunity of obtaining the opinion 
of the public more at large, and thereby be enabled ei- 
ther to vindicate my do6'trines,or be taught to correct them. 
Thefe were the motives for my attempting the Volumes I 
formerly publifhed ; and now, from many years experi- 
ence of their utility to my hearers, as well as from the fa- 
vourable reception they have met with from the Public, 
I am induced to give a new edition of this Work, not or- 



PREFACE. 21 

ly, as I hope, more correct in many parts, but alfo more 
complete and comprehenfive in its general extent. 

at the firft publication of this Work, it was intended 
chiefly for the ufe of thofe Gentlemen who attended my 
Lectures : Although, even then, for the reafons I have 
mentioned, it was rendered more full than Text books 
commonly are ; and, in the repeated Editions I have fince 
had occafion to give, I have been conftantly endeavour- 
ing to render it more full and comprehenfive. In thefe 
refpetts, I hope the prefent edition will appear to be ren- 
dered more fit for general ufe, and better calculated to af- 
ford fatisfaction to all thofe who think they may ftill re- 
ceive any inftruction from reading on thisfubject. 

while I thus deliver my Work in its now more im- 
proved ftate, with the hopes that it may be of ufe to oth- 
ers as well as to thofe who hear my Lectures, I mufl at 
the fame time obferve, that it prefents a fyftem which is 
in many refpects new ; and therefore I apprehend it to be 
not only proper, but neceflary, that I fhould explain here 
upon what grounds, and from what confederations, this 
has been attempted. 

in the firft place, I apprehend, that, in every branch of 
fcience with refpeft to which new fads are daily acquired, 
• and thefe confequently giving occafion to new reflections, 
which correct the principles formerly adopted, it is necef- 
fary, from time to time, to reform and renew the whole 
fyftem, with all the additions and amendments which it 
has received and is then capable of. That at prefent this 
is requifite with regard to the Science of Medicine, will, I 

believe, 



22 



PREFACE. 



believe, readily occur to every perlon who at all thinks 
for himfelf, and is acquainted with the Syftems which have 
hitherto prevailed. While, therefore, I attempt this, I 
think it may be allowable, and upon this occafion even 
proper^ that I fliould offer fome remarks on the principal 
Syftems of Medicine which have of late prevailed in Eu- 
rope, and that I mould take notice of the prefent Rate of 
Phyfic as it is influenced by thefe. Such remarks, 1 hope, 
may be of fome ufe to thofe who attempt to improve their 
knowledge by the reading of books. 

whether the Practice of Phyfic fhould admit of rea- 
foning, or be entirely refled upon experience, has long 
been, and may Mill be, a matter of difpute. I fhall not, 
however, at prefent enter upon the difcuffion of this ; be- 
caufe I can venture to aflert, that, at almoft all times, the 
praaicehas been, and ftill is, with every perfon, founded, 
more or lefs, upon certain principles eftablifhed by rea- 
foning : And therefore, in attempting to offer fome view 
of the prefent ftate of Phyfic, I muff give an account of 
thofe fyftems of the principles of the fcience which have 
lately prevailed, or may be fuppofed ftill to prevail, ia 
Europe. 

when, after many ages of darknefs, which had deftroy- 
ed almoft the whole of ancient literature, learning was a- 
gain reftored in the fifteenth century ; fo, from caufes* 
which are well known, it was the fyftem of Galen alone 
that the Phyficians of thofe days became acquainted with ; 
and during the courfe of the fixteenth century, the fhidy 
of Phyficians was almoft folely employed in explaining 
and confirming that fyftem. Early, indeed, in the fix- 
teenth. 



PREFACE. «3 

teenth century, the noted Paracelfus had laid the founda- 
tion of a Chemical Syftem which was in dire&oppofition to 
that of Galen ; and, by the efficacy of the medicines em- 
ployed by Paracelfus and his followers, their fyftem came 
to be received by many : But the fyftematic Phyficians 
continued to be chiefly Galenifts, and kept pofleflion of 
the Schools till the middle of the feventeenth century. It 
is not, however, neceflary here to enter into any further 
detail refpe&ing the fate of thofe two oppofite fects ; for 
the only circumftance concerning them, which I would 
wifti at prefent to point out, is, that, in the writings of 
both, the explanations they feverally attempted to give of 
the phasnomena of health or ficknefs turned very entirely 
«pon the ftate of the fluids of the body. 

such was the ftate of thefcience of Phyfic till about the 
middle of the feventeenth century, when the circulation 
©f the blood came to be generally known and admitted; 
and when this, to§ether with the difcovery of the recepta- 
cle of the chyle, and of the thoracic duel, finally exploded 
the Galenic fyftem. About the fame period, a confidera- 
ble revolution had taken place in the fyftem of Natural 
Philofophy. In the courfe of the feventeenth century, 
Galileo had introduced mathematical reafoning ; and Lord 
Bacon having propofed the method of induction, had 
thereby excited a difpofi^on to obferve fafts, and to make 
experiments. Thefe new modes of philofophizing, it 
might be fuppofed, would foon have had fome influence 
en the ftate of medicine ; but the progrefs of this was flow. 
The knowledge of the Circulation did indeed neceflarily 
lead to the confideration as well as to a clearer view of the 
Organic Syftem in animal bodies ; which again led to the 

application 



24 PREFACE. 

application of the mechanical philofophy towards explain- 
ing the phsenomena of the animal economy ; and it was 
applied accordingly, and continued, till very lately, to be 
the fafhionable mode of reafoning on the fubjeft. Such 
reasoning, indeed, mult ftill in ieveral refpeds continue to 
be applied : But it would be eafy to fhow, that it neither 
could, nor ever can be, applied to any great extent in ex- 
plaining the animal economy ; and we muft therefore look 
for other circumftances which had a greater fhare in 
modelling the fyftem of Phyfic. 

with this view it may be remarked, that, till the pe- 
riod juft now mentioned, every Phyfician, whether Ga- 
leniftor Chemift, had been fo much accuftomed to con- 
fider the ftate and condition of the fluids, both as 
the caufe of difeafe, and as the foundation for explaining 
the operation of medicines, that what we may term an Hu- 
moral Pathology (till continued to make a great part 
of every fyftem. In thefe circumftances, it was foon per- 
ceived, that chemiftry promifed a much better explana- 
tion than the Galenic or Ariftotelian philofophy had 
done ; and, therefore, while the latter was entirely laid a- 
fide.a chemical reafoning was every where received. Lord 
Bacon, with his ufual lagacity, had early obferved, that 
chemiftry promifed a great number of fails, and he there- 
by gave it credit ; whilft the Corpufcularian philofophy, re- 
ftoredbyGaflendi, readily united with the reafonir.gs of the 
Chemifts ; and the philofophy of Des Cartes readily unit- 
ed with both. From all thefe circumftances, an Humoral, 
and chiefly a Chemical Pathology, came to prevail very 
much till the end of the laft century ; and has, indeed, 

continued 



PREFACE. 25 

continued to have a great (hare in our fyftems down to the 
prefent time. 

it is proper now, however, to obferve, that about the be- 
ginning of the prefent century, when every part of fcience 
came to be on a more improved and correct footing, there 
appeared in the writings of Stahl, of Hoffman, and of 
Boerhaave, three new, and confiderably different, Syf- 
tems of Phyfic ; which have ever fince had a great fhar« 
in directing the practice of it. In order, therefore, to 
give a nearer view of the prefent ftate of Phyfic, I fhall of- 
fer fome remarks upon thefe different fyftems ; endeavour- 
ing to point out the advantages as well as the difadvan- 
tages of each, and how far they ftill prevail ; or, ac- 
cording to my judgment, deferve to do fo. 

1 shall begin with confideringthat of Dr. Stahl, which 
I think appeared firft, and for a long time after was the 
prevailing fyftem in Germany. 

the chief and leading principle of this fyftem is, that 
the rational foul of man governs the whole economy of 
his body. At all times, Phyficians have obferved, that 
the animal economy has in itfelf a power or condition, by 
which, in many inftances, it refifls the injuries which 
threaten it ; and by which it alfo, on many occafions, cor- 
rects or removes the diforders induced, or arifing in it. 
This power, Phyficians very anciently attributed, under a 
vague idea, to an agent in the fyftem, which they called 
nature ; and the language of a vis confervatrix et tned- 
uatrix naturae, has continued in the fchools of medicine 
from the mofl ancient times to the prefent. 

B DR. 



26 PREFACE. 

DR. Stahl has explicitly founded his fyftem on the 
kippofition, that the power of nature, fo much talked of, 
is entirely in the rational foul. He fuppofes, that, upon 
many occafions, the foul afts independently of the ftate of 
the body ; and that, without any phyfical neccflity arifing 
from that ftate, the foul, purely in confequence of its in-' 
telhgence, perceiving the tendency of noxious powers 
threatening, or of diforders anywife arifing in the fyftem, 
immediately excites fuch motions in the body as are fuited 
to obviate the hurtful or pernicious confequences which 
might othervvife take place. Many of my readers may 
think it was hardly neceflary for me to take notice of a 
fyftem founded upon fo fanciful a hypothefis ; but there is 
often fo much feeming appearance of intelligence andde- 
iign in the operations of the animal economy, that many 
eminent perfons, as Perrault in France, Nichols and Mead 
in England, Porterfield and Simfon in Scotland, and 
Gaubius in Holland, have very much countenanced the 
fame opinion, and it is therefore certainly entitled to fome 
regard. It is not, however, neceflary for me here to en- 
ter into any refutation of it. Dr. Hoffman has done this 
fully, in his Commentarius de differentia Inter Hoffmanni 
dotlrinam med'ico-mechanicam et G, E. Stahlii medico organ- 
team', and both Boerhaave and Haller, though no favour- 
ers of materialifm, have maintained a doctrine very oppa- 
fite to that of Stahl. 

in my Phyfiology I have offered fome arguments againft 
the fame •, and I fhall only add now, that whoever confid- 
ers what has been faid by Dr. Nichols in his Oratio de An* 
vna Medica, and by Dr. Gaubius in fome parts of his 
Pathology, muft perceive, that the admitting of fuch a 
capricious government of the animal economy, as thefe 

authors 



PREFACE. 27 

authors in fome inftances fuppofe, would at once lead us 
to reject all the phyfical and mechanical reafoning we 
might employ concerning the human body. Dr. Staid 
himfelf feems to have been aware of this ; and therefore, 
in his Preface to Juncker's Confpeclus Tbcrape'ice Spcrialis, 
has acknowledged, that his general principle was not at 
all neceffary ; which is in effect: faying that it is not com- 
patible with any fyftem of principles that ought to govern 
our practice. Upon this footing, I might have at once 
rejedted the Stahlian principle .- But it is even dangerous 
to bring any fuch principle into view ; for, after all Dr. 
Stahl had faid in the paffage juft now referred to, I find, 
that, in the whole of their practice, both he and his fol- 
lowers have been very much governed by their general 
principle. Truffing much to the conflant attention and 
wifdom of nature, they have propofed the Art 0/ curing by 
expectation ; have therefore, for the mod part, propofed 
only very inert and frivolous remedies ; have zealoufly 
oppofed the ufe of fome of the mod efficacious, fuch as o- 
pium and the Peruvian bark ; and are extremely referved 
in the ufe of general remedies, fuch as bleeding, vomiting, 
&c. 

although thefe remarks, upon a fyftem which may 
now be confidered as exploded or neglected, may feem 
fuperfluous ; I have been willing to give thefe ftrictures 
on the Stahlian fyftem, that I might carry my remarks a 
little farther, and take this opportunity of obferving, that, 
in whatever manner we may explain what have been call- 
ed the operations of nature, it appears to me, that the gen- 
eral doctrine of Nature curing difeafer, the fo much vaunt- 
ed Hippocratic method of curing, has often had a very 
baneful influence on the practice of phyfic ; as either lead- 

B 2 wj 



28 PREFACE. 

ing phyficians into, or continuing them in, a weak and fee- 
ble practice ; and at the fame time fuperfeding or difcour- 
aging all the attempts of art. Dr. Huxham has properly 
obferved, that even in the hands of Sydenham it had this 
efTecT:. Although it may fometimes avoid the mifchiefs of 
bold and ram practitioners, yet it certainly produces that 
caution and timidity which have ever oppofed the intro- 
duction of new and efficacious remedies. The oppofition 
to chemical medicines in the fixteenth and feventeenth 
centuries, and the noted condemnation of Antimony by the 
Medical Faculty of Paris, are to be attributed chiefly to 
thofe prejudices, which the phyficians of France did not 
entirely get the better of for near a hundred years after. 
We may take notice of the referve it produced in Boer- 
Iiaave, with refpedt to the ufe of the Peruvian Bark. We 
have had lately publifhed, under the title of Conjlitutienes 
Epidemlcce, notes of the particular practice of the late 
Baron Van Swieten ; upon which the editor wry properly 
obferves, That the ufe of the bark, in intermitting fevers, 
appears very rarely in that practice ; and we know very 
well where -Van Swieten learned that referve. 

l might go farther, and fliow how much the attention 
to the Autocrateia, allowed of, in one fhape or other, by 
every feet, has corrupted the practice amon^ all phyfi- 
cians, from Hippocrates to Stahl. It muff, however, be 
fufficicntly obvious, and I fliall conclude the fubject with 
obferving, that although the nj'ts tvdicatrix natura muft 
unavoidably be received as a fact ; yet, wherever it is ad- 
mitted, it throws an obfeurity upon our fyfiem ; and it is 
only where the impotence of our art is very manifeft and 
..confiderable, that we ought to admit of it in practice. 



.TO 



PREFACE. 29. 

to finifh our remarks upon the Stahlian Syftem, I (hall 
fliortly obferve, that it did not depend entirely upon the 
Autocrate'ia, but alfo fuppofed a ftate of the body and d;<- 
eafes, that admitted of remedies ; which, under the power 
and direction of the foul, acted upon the organization and 
matter of the body, fo as to cure its difeafes. Upon this 
footing, the Stahlian pathology turned entirely upon Pleth- 
ora and Cacochymy. It was with refpect to the former 
that they elpecially applied their doctrine of the Autocr*- 
tela in a very fanatical manner ; and, with refpect to the 
latter, they have been involved in a humoral pathology as 
much as the fyftematic phyficians who had gone before 
them, and with a theory fo incorrect as not to merit now 
the fmalleft attention. After all, I ought not to difmifs the 
confideration of the Stahlian fyltem, without remarking, 
that as the followers of this fyftem were very intent upon 
obferving the method of nature, fo they were very atten- 
tive in obferving the phenomena of difeafes, and have giv- 
en us in their writings many facts not to be found elfe- 
where. 

while the doctrines of Stalil were prevailing in the u- 
niverfity of Halle, Dr. Hoffman, a profeffor in the fame 
univerfity, propofed a fyflem that was very different. He 
received into his fyftem a great deal of the mechanical, 
Cartefian, and chemical doctrines of the fyftems which 
had appeared before : But, with refpect to thefe, it i» or 
no confequence to obferve in what manner he modified 
the doctrines of his predeceflors, as his improvements in > 
thefe refpects were no ways confiderable, and no part of 
them now remain ; and the real value of his works, be- 
yond what I am juft now going to mention, refts entirely 
B3 9m 



30 PREFACE. 

•n the many fa&s they contain. The merit of Dr. Hoff- 
man and of his works is, that he made, or rather fuggefted, 
an addition to the fyftem, which highly deferves our atten- 
tion. Of this I cannot give a clearer account than by giving 
it in the author's own words. In his Mcdicina Rationalis 
I SyJiematica,Tom. III. \ I. chap. 4. he has given his Gene- 
alogia morborum ex turbato foltdorum, ctjlu'idorum mechanlj. 
mo ; and in the 47th and lart paragraph of this chapter, he 
funis up his doctrine in the following words : Ex hlfce au- 
tem omnibus, uberius haclenus excufts, per quam dUuc'ide ap- 
parere arbitror, quod folus spasmus etfimplex atonia, a- 
quabilem, liberum, ac proportionatum fanguinis omnifque gen- 
eris fluidorum motum, qu'ibus excretionum Juccejfus et integri- 
tasfunclionum anim'i et corporis froxime nititur, turbando ac 
pervertendo, uni e verfam <vitalcm ceconomiam fubruant ac dcf- 
iruant ; atque hincunin>erfa pathologia longe retlius atque facil- 
JKJEX VITIO M0TUUMMICR0COSMICORUM1NS0LIDI9, 
quam EX VARUS AFFECTIONIBUSVITIOSORUM HUM CD- 
RUM, deduct atque explicari poj/it, adcoque omnis generis a- 
gritudines interna, ad pr^eternaturales GENERIS 
nervosi affection zsjint referenda. Etcnim lajis quo- 
cunque modo, n>el nervis per corpus di/currentibus, njel mem- 
branojis quibupvis nervojis partibus, illico motuum anomaUa, 
modo Icviores, modo grat'iores Jubfequuntur. Deinde attenta 
obferwatio docct, motus quof<vis morbofos principaliter fedcm 
fgere et tyrannidem exercere in newofis corporis partibus, 
cuj us generis prater omnes canales, qui fyflaltico et diaftalti- 
co motu polkntes, contcntos fuccos traditnt, uninjerfutn niml- 
rum intejlinorum et <ventriculi ab aefophago ad anum cana- 
lem, totum fyflema <vaforum arterioforum, dutluum biliario- 
rnm,fa!i<valiu?n, urinariorum et fubcutaneorum,funt quoque 
rnembrana nerveo-mufculares cerebri et medulla fpinalis, 
prafertim bac, qua dura mater vacatur, organis fenforih 

obducJa, 



PREFACE. 31 

tbducla, nee non tunica ilia ac ligamcnta, qua ojfa cingunf 
artufque jxrmant. Nam nullus dolor, nulla injlammatio, 
nullus fpajnms , nulla tnotus et fenfus impotentia, nulla febris 
aut humoris illius exeretlo, aceidit, in qua non ha partes pa- 
lianiur. Porro etiam omnes, qua morbos gignurtt caufa, 
eperationem fuam potiJft?nam perficiunt in partes mciu et 
fu praditas, et canales ex his coagmen/atos, eorum motutn, 
et eum hoe fiuidorum eurfum, pcrnjertendo ; ita tartieit, ut 
ficuti <varia indolis funt, fu etiam <varie in nerveas partes a- 
gant, iifdemque noxam affricent. Demum omnia quoquc c . 
'virtutis medicamenta, non tarn in partis fluidat, eatum ac- 
Jin ac intemperiem corrigendo, quam potius in folidas et 
newofas, earundem motus alterando ac moderando, 
edunt eperationem : De quibus tamen omnibus, in vulcari uf- 
que eo recepta morborum doclrina, ahum ejl filentium. 

it is true that Dr. Willis had laid a foundation lor this 
doctrine, in his Pat-hologia Cerebri et Nervorum ; ami 
livi had propoled a fyfiem of this kind in his Specimen de 
fibra motrici et morbofa. But, in thefe writers, it was ei- 
ther not extenfively applied to difealcs, or was ftill fo ii - 
volved in many phyfiological errors, that they had at- 
tracted little attention ; and Dr. Hoffman was the firft 
who gave any tolerably funple and clear fyftem on tiic 
fubject, or pointed out any extenfive application of it to 
the explanation of difeafes. 

there can be no fort of doubt that the phenomena of. 
the animal economy in health and in ficknefs, can only be 
explained by confidering the flate and affections of the 
primary moving powers in it. It is to me furprifing that 
phyficians were fo long of perceiving this, and I think we- 
are therefore particularly indebted to Dr. Hoffman forr 
B.4. Ruttiii- 



32 PREFACE. 

putting us into the proper train of investigation ; and it 
every day appears that Phyficians perceive the necefiity 
ofentering more and more into this inquiry. It was this, 
I think, which engaged Dr. Kaavv Boerhaave to publifh 
his work intitled lmpetum fac'iens ; as well as Dr. Gaubius 
to give fne Pathology of the Solidum v'pvum. Even the 
Baron Van Swieten lias upon the fame view thought it 
neceflary, in at leaft one particular, to make a very con- 
siderable change in the doctrine of his matter, as he has 
done in his Commentary upon the 755th Aphorifm. Dr. 
Haller lias advanced this part of fcience very much by his 
experiments on irritability and lenfibility. In thefe and in 
many other instances, particularly in the writings of Mr. 
Barthez of Montpelier, of fome progrefs in the fludy of 
the affeftions of the Nervous Syftem, we mud perceive 
how much we are indebted to Dr. Hoffman for his fo 
properly beginning it. The fubject, however, is difficult : 
The laws of the Nervous Syftem, in the various eircum- 
ifances of the animal economy, are by no means afcer- 
tained ; and, from want of attention and obfervation with 
the view to a fyftem on this fubject, the bufinefs appears 
to many as an inexplicable myftery. There is no wonder, 
therefore, that, on fuch a difficult fubject, Dr. Hoffman's 
fyftem was imperfect and incorrect ; and has hadlefs in- 
fluence on the writings and practice of Phyficians fince 
his time, than might have been expected. He himfelf has 
not applied his fundamental doctrine fo extenfively as he 
might have done ; and he has every where intermixed an 
Humoral Pathology as incorrect and hypothetical as any 
other. Though he differed from his colleague Dr. Stahl 
in the fundamental doctrines of his fyftem, it is but too 
evident that he was very much infected with the Stahlian 

doctrines 



P R E F A C E. 33 

<k>6trines of Plethora and Cacochymy, as may be obferv- 
ed throughout the whole courfe of his work ; and particu- 
larly in his chapter De morborum generatione ex nimia fan- - 
guinis quantitateet humorum impuritat*. 

but it is needlefs for me to dwell any longer upon the ' 
fyftem of Hoffman ; and I am next to offer forae remarks 
on the fyftem of Dr. Boerhaave the cotemporary of both 
the other Syltematics, and who, over all Europe, and ef~ 
pecially in this part of the world, gained higher reputa- 
tion than either of the others. . 

DR.* Boerhaave was a man of general erudition ; and, 
in applying to medicine, he had carefully ftudied the aux- 
iliary branches of Anatomy, Chemiltry, and Botany, (o 
that he excelled in each. In forming a Syftem of Phyfic, 
hefeems to have ftudied diligently all the feveral writ- 
ings of both ancient and modern phyficians ; and, without 
prejudice in favour of any former fyftems, he endeavour- . 
ed to be a candid and genuine ecclectic. Poffeffed of an 
excellent fyftematic genius, he gave a fyftem fuperior to 
any that had ever before appeared; As in the great ex- 
tent, and feemingly perfect ccnfiftency, ot fyftem, he ap- 
peared to improve and refine upon everything that had 
before been offered ; and as in his Lectures he explained 
his doctrines with great clearnefs and elegance ; he foon 
acquired a very high reputation, and his fyftem was more 
generally received than any former had been fince'the 
time of Galen. Whoever will confider the merits of Dr. 
Boerhaave, and can compare his fyflem with that of form- 
er writers, mult acknowledge that he was verv juftly ef- 
teemed, and gave a fyftem which was at that time deierv- 

edly valued. . 

B 5 - sut/ 



34 PREFACE. 

but, in the progrefs of an inquifitive and induftrious 
age, it was not to be expected that any fyftem fhould laft 
fo long as Boerhaave's has done. The elaborate Com- 
mentary of Van Swieten on Boerhaave's fyftem of prac- 
tice, has been only finifhed a few years ago ; and though 
this Commentator has added many facts, and made fome 
corrections, he has not, except in the particular mention- 
ed above, made any improvement in the general fyftem. 
It is even furprifing that Boerhaave himfelf, though he 
lived near forty years after he had firft formed his fyftem, 
had hardly in all that time made any corrections of it or 
additions to it ; the following is the moft remarkable. In 
Aphorifin 755, the words forte et nernjojl, tarn cerebri quam 
cerebelli cordi defiinati inertia, did not appear in any e- 
dition before the fourth ; and what a difference of lyftem 
this points at, every phyfician mult perceive. 

when I firft applied to the ftudy of Phyfic, I learned 
only the fyftem of Boerhaave ; and even when I came to 
take a Profeflbr's chair in this univerfity, I found that fyf- 
tem here in its entire and full force ; and as I believe it 
(till fubfifts in credit elfewhere, and that no other fyftem 
of reputation has been yet offered to the world, I think it 
neceflary for me to point out particularly the imperfec- 
tions and deficiencies of the Boerhaavian fyftem, in order 
to fhow the propriety and neceflity of attempting a new 
one. 

to execute this, however, fo fully as I might, would" 
lead me into a detail that can hardly be admitted of here • 
and I hope it is not neceffary, as I think, that every intel- 
ligent perfon, who has acquired any tolerable knowledge 
of the prefent flateof our fcienee, muft, in manyinftances, 

perceive 



P R ■ E F A C E: 






perceive its imperfections. I fhall therefore touch only 
upon the great lines of this fyftem ; and from the remarks ; 
lam to offer, trult that both the miftakes and deficiencies, 
which run through the whole of his works will appear. 

dr. Boerhaave's treatife of the difeafes of the fimple 
folid, has the appearance of being very clear and confid- 
ent, and was certainly confidered by him as a fundamental 
doctrine ; but, in my apprehenfion, it is neither correct. 1 
nor extenfively applicable. Not to mention the ufelefs, 
and perhaps erroneous, notion of the compofition of earth' 
and gluten ; nor his miftake refpecting the ffructure of 
compound membranes ; nor his inattention to the Mate of 
the cellular texture ; all of them circumffances which 
render his doctrine imperfect ; I fhall infift only upon the 
whole being very little applicable to the explaining the 
phenomena of health or ficknefs. The laxity or rigidity 
of the fimple folid, does, indeed, take place at the differ- 
ent periods of life, and may perhaps, upon other occafions, . 
occur as the caufe of difeafe : But I prefume, that the-' 
irate of the fimple folid is, upon few occafions, either 
changeable or actually changed ; and that, in ninety nine 
cafes of an hundred, the phenomena attributed to fuch a 
change, do truly depend on the Plate of xhtfolidum <vi<vum ; 
a circumftance which Dr. Boerhaave has hardly takeiv 
notice of in any part of his works. Kow much this fhows 
the deficiency and imperfection of his fyftem, I need not 
explain. The learned work of Dr. Gaubius, above re- 
ferred to, as well as many other treatifes of late author?, 
point out fuftkiently the defects and imperfections of 
Boerhaave on this fubject. 

after Dr. Boerhaave has confidered the difeafes of the* 

fclids, lie in the next place attempts to explain the more : 

B6 fuiir'.s.' 



36 PREFACE. 

fimple difeafes of the fluids ; and there, indeed, he deliv- 
ers a more correct doctrine of acid and alkali than had 
been given before : But, after all, he has done it very im- 
perfectly. We have, indeed, fince his time, acquired more 
knowledge upon the* fubjeel of digeflion ; and fo much as 
to know, that a great deal more is yet neceflary to enable 
us to underttand in what manner the animal fluids are 
formed from the aliments taken in. And although Dr. 
Boerhaave has fallen into no confiderable error with re- 
ipedt to a morbid acidity in the ftomach, lie could not pol- 
fibly be complete upon that fubjeel ; and his notion of the 
effects of acidity in the mafs of blood feems to have been 
entirely millaken, and is indeed not confident with what he 
himfelf has delivered elfewhere. 

his doctrine of alkali is fomewhat better founded, but 
is probably carried too far ; and the Mate of alkalefcency 
and putrefaction, as well as all the other changes which 
can take place in the condition of animal fluids, are par- 
ticulars yet involved in great obfeurity, and are therefore 
full fubjefts of difpute. 

there is another particular, in which Boerhaave's doc- 
trine concerning the fluids appears to me imperfect and 
unfatisfactory ; and that is, in his doctrine de Glutinofo 
fpontaneo. The caufes which he has afligned for it are by 
no means probable, and the actual exiftence of it is feldom 
to be proved. Some of the proofs adduced for the exifr- 
ence of the phlegma calidttm, are manifeftly founded on a 
miftake with refpect to what has been called the inflam- 
matory cruft, (fee Van Swieten's Commentary, page 96) • 
and the many examples given by Boerhaave of a glutinofum 
appearing in the human body, (Apb. 75.) are all of them 

nothing 



P. R E F A C E. 37 

nothing more than inflances of collections or concretions 
found out of the courfe of the circulation. 

if, then, we confider the imperfection of Dr. Boer- 
haave's dodrine with refpecl to the ftate and various con- 
dition of the animal fluids ; and if at the fame time we re- 
flect how frequently he and his followers have employed 
the fuppofition of an acrimony or lentor of the fluids, as 
caufes of difeafe, and for direfting the practice ; we muft, 
as I apprehend, be fatisfied, that his fyftem is not only de- 
ficient and incomplete, but fallacious and apt to miflead. 
Although it cannot be denied, that the fluids of the hu- 
man body fuffer various morbid changes ; and that upon 
thefe, difeafes may primarily depend ; yet I muft beg leave 
to maintain, that the nature of thele changes is feldom un- 
derftood, and more feldom ftill is it known when they 
have taken place : That our reafonings concerning them, 
have been, for the mod part, purely hypothetical ; have 
therefore contributed nothing to improve, and have often 
milled the practice of phyfic. In this, particularly, they 
have been hurtful, that they have withdrawn our attention 
from, and prevented our ftudy of, the motions of the ani- 
mal lyftem, upon the (late of which the phenomena of dif- 
eales do more certainly and generally depend. Whoever, 
then, fhall confider the almoft total neglect of the flare of 
the moving powers of the animal body, and the prevalence 
of an hypothetical humoral pathology, fo confpicuous in 
every part of the Boerhaavian Syftem, mult be convinced 
of its very great defects, and perceive the neceflity of at- 
tempting one more correct. 

after giving this general view, it is not requifite to en- 
ter into particulars : But, I believe, there are very few 

pages 



3# PREFACE. 

pages of his aphorifms in which there does not occur iomc 
error or defect; although, perhaps, not to be imputed to* 
Hie fault of Boerhave, fo much as to this, that fince his 
time a great eolleftion of new facts has been acquired by 
obfervation and experiment. This indeed, affords the bed 
and moft folid reafon for attempting a new fyftem : For 
when many new facts have been acquired, it becomes requi- 
fite that thefe fhould be incorporated into a fyftem, where- 
by not only particular fubjects may be improved, but the 
whole may be rendered more complete, confident, and 
ufeful. Every fyftem, indeed, mud be valuable in pro- 
portion to the number of facts that it embraces and com- 
prehends ; and Monf. Quefney could not pay a higher 
compliment to the Syftem of Boerhaave, than by faying 
that it exhibited La medicine colletli've. 

but here it will, perhaps, be fuggefted to me, that the- 
only ufeful work on the fubje£t of Phyfic, is the making 
a collection of all the facts that relate to the art, and 
thereforeof all that experience has taught us with refpect. 
to the cure of difeafes. I agree entirely in the opinion ; 
but doubt if it can ever be properly accomplifned, with- 
out aiming at fome fyftem of principles, by a proper in- 
duction and generalifation of facts : At leaft I am per- 
fuaded that it can be done not only very fafely, but moft 
ufefully in this way. This, however, muft be determin- 
ed by a trial. I know that the late Mr. Lleutaud has at- 
tempted a work on the plan of collecting facts without 
any reafoning concerning their caufes : And while I am 
endeavouring to give fome account of the prefent Rate of 
Phyfic, I cannot difmifs the fubject without offering fome 
remarks upon the promifing Synopfu uni<verfa> medicin« % 

coir.pofed. 



PREFACE. 39> 

compofed by the firft phyfician of a learned and ingenious, 
nation. 

in this work there are many fafts and much obferva- 
tion from the Author's own experience, which maybe 
ufetul to thofe who have otherwife acquired fome knowl- 
edge and difcernment ; but, throughout the whole work, 
there is fuch total want of method, arrangement, fyftem, 
or decifion, that, in my humble opinion, it can be of little 
ufe, and may prove very perplexing to thofe who are yet 
to learn. The distinction of the genera of difeafes, the 
diftin&ion of the fpecies of each, and often even that of 
the varieties, I hold to be a neceffary foundation of every 
plan of Phy fie, whether Dogmatical or Empirical. But 
very little of this diflin&ion is to be found in the work of 
Mr. Lieutaud ; and in his preface he tells us, that he 
meant to neglefl fuch arguta feduiitat. And indeed his 
method of managing his fubjecl mud certainly interrupt 
and retard all methodical nofology. His arrangement of 
difeafes is according to no affinity, but that of the flighteft 
and uninftructive kind, the place of the body which they 
■ happen to affect. His Generalia et iticerta fedis, have 
hardly any connexion at all ; the titles Rbeumatifms, Hy- 
pochondriafis, Hydrops, follow one another. When he does 
attempt any general doctrine, it is not till long after he 
lias treated of the widely fcattered particulars. Under 
each particular title which he afTumes, he has endeavour- 
ed to enumerate the whole of the fymptoms that ever ap- 
peared in a difeafe under that title ; and this without 
aiming at any diftinclion between the eflential and acci- 
dental fymptoms, or marking the feveral combinations 
Under which thefe iymptoms do for the mod part fteadily 

appear. 



40 PREFACE. 

appear. From the concurrence of accidental fymptoms,". 
the variety of the fame difeafe is frequently confiderable, 
a circumftance neceflarily perplexing and diffracting to 
young practitioners ; but it feems fhange to me, that an 
experience of thirty years, in confiderable practice, could 
do nothing to relieve them. 

mr. Lieutaud has at the fame time increafed the con- 
fufion that mud arife from this want of diftin&ion, by 
his confidering as primary difeafes, what appear to me to 
be the fymptoms, effects, and fequels, of other difeafes 
only. Of this I think the JEJlus morbofus, Virum exolutio, 
Dolores, Stagnatio Sanguinis, Purulentia, Tremor, Pervigili- 
um, Raucedo, Suffocatio, Vomica, Empyema, Singultus, Vom- 
itus Dolor Stomachi, Tenefmus, all treated of under fepa- 
rate titles, are examples. A general fymptomatologia may 
be a very ufeful work, with a view to a Syftem of Patholo- 
gy ; but, with a view to practice without any Syftem, it 
muff have bad effects, as leading only to a palliative 
practice, and diverting from the proper efforts towards 
obtaining a radical cure. Mr. Lieutaud, indeed, has en- 
deavoured to exhibit the fymptoms above mentioned as 
fo many primary difeafes ; But he has feldom fucceeded in 
this ; and, in delivering the practice, he commonly finds • 
it neceflary to confider them as fymptoms, and that not 
without fome theory, implied or exprefTed, with refpect 
to their proximate caufes. His title of Dolores may be tak- 
en as an example of this ; and from which it may be 
readily perceived how far fuch treatifes can be really, 
ufeful. 

in efiablifhing a proper pathology, there is nothing that 
has been of more fervice than the DifTettion of morbid 

bodies. 



PREFACE. 



41 



bodies. Mr. Lieutaud has been much and mod com- 
mendably employed in this way, and rn this Synopfis he 
has endeavoured to communicate his knowledge on the 
fubjecT: ; but, in my humble opinion, he has feldom done 
it in a manner that can be uleful. In the fame way that 
he has delivered the fymptoms of difeafes without any 
inftructive arrangement; fo, on thefubjeft of the appear- 
ances after death, he has mentioned every morbid appear- 
ance that had ever been obferved after the difeafe of 
which he is then treating ; but thefe appearances are 
ftrangely huddled together, without any notice taken of 
thofe which belong to one fet of fymptoms or to another ; 
and, with regard to the whole, without any attempt to 
diflinguifh between the caufes of difeafes and the caufes 
of death ; although the want of fuch diftinftion is the 
well known ground of fallacy upon this fubject. I take 
for an example, the appearances mentioned as having been 
obferved after dropfy. Here morbid appearances, fovtnd 
in every part of the body, in every cavity of it, and in ev- 
ery vifcus contained in thefe cavities, are enumerated ; 
but which of thefe morbid ftates are more frequent or 
mere rare, and which had been more particularly con- 
nected with the different caufes, or with the different ftate 
of fymptoms previoufly recited, we are not informed, nor 
lias he enabled us to difcover. In fhort, the diffeftion ot 
morbid bodies has been, and may be, highly ufeful ; but 
in order to be fo, it mufl be under a different management 
from what we find, either in this Synopfis, or even in the 
H/Jloria Anatom'tco-mcdica. 

1 cannot difmifs this fubjeft without remarking, that 
the direction of morbid bodies, is chiefly valuable upon 

account 



42 PREFACE. 

account of its leading us to difcover the proximate caufes- 
of difeafes ; and the great and valuable work of the illuf- 
trious Morgagni,is properly intitled Defcdibus ct causis. 
It may well feem furprifing, then, that Lieutaud mould 
find the whole of proximate caufes atra caligme tncrfas ; 
and that he mould never have thought of applying his 
dificcYion towards the afcertaining at lead fome of tlicfe. 

rut let ine now proceed to confider the important part 
•f every practical work, and of this Synopfis unkverf* tncdU 
una ; that is, the method of curing difeafes. 

here, again, \ipon the fame plan as in giving the hiflories 
of difeafe, the method of cure is delivered»by enumerating 
the whole of the remedies that have ever been employed 
in a difeafe under the title prefixed ; without afligning the 
ipecies, or the circumftances to which the remedies, 
though of a very different and fometimes oppofire nature, 
are peculiarly adapted . On the fubjeft. of Afthma, he very 
juftly obferves that physicians have been to blame in con- 
founding under this title, almoft all the fpecies of Dyf- 
pncea ; and he himfelf very properly confiders AJhma as 
a difeafe dirtincl from all the other cafes of Dyfpncea. Still, 
however, he confiders Afthma as of many different fpecies, 
arifing from many different caufes, which, till we under- 
ftand better, we cannot attempt to remove. Notwithfiand- 
ingall this, he proceeds to deliver a very general cure. 
Parum abejl, fays he, quln [peafici tilulo gaudeant pefloralia, 
njulneraria, et incidenual But from fuch language I receive 
no clear idea ; nor can I obtain any clear direction from 
the enumeration of his medicines. Bacc<e jumperi, gumtni 
tragacanthum vel atnmon'iacum,fapo, aquapicea, tercbinthi- 
na, @c. qya tatnen baud indifcriminatimfuntufurpanda, fed ! 



PREFACE. 43 

fro re nata, delcclu opus eft. Very juflly indeed, deleilu 
•pus eft ; but here, as in many other inftances, lie gives us 
no fort of affiffance, 

from his endeavours, though not always fuccefsful, to 
neglect all fyflem, his practice is generally delivered in a 
very indecifive manner; or, what has the fame effect, in a 
way fo conditional as will render it always difficult, and 
•ften impoflible, for a young practitioner to follow him. 
Let us take, for example, his cureof Dropfy. " The cure 
" may be begun by bloodletting in certain conditions ; 
" but, in others, it cannot be employed 'without danger. It 
" gives relief in difficult breathing ; but, after it is praclif- 
" ed, the fymptoms are aggravated, and rendered more obfti- 
'* nate. It is not to.be concealed that fome perfons have 
"been cured by repeated bloodlettings, or fpontaneous 
" hjemorrhagies ; but it is at the fame time known, thatfucb 
" a remedy inopportunely employed, has in many inftances haf- 
" tened on the fatal event." 

in the fame manner he treats of vomiting, purging, 
fweating, and the ufe of mineral waters ; but I mufl con- 
fefs, that he has no where removed any of my doubts or 
difficulties, and indeed he has fometimes increafed them. 
He fays, that hepatics, or aperients, fuchas the lingua cer- 
mina, herb<e capillares, &c. deferve commendation ; but 
that, v\ lien the difeafe has arifeu to a certain degree, they 
have bcen./o/- the moft part, found to be ufelefs. Heobferves, 
that the powder of toads given in wine, to the quantity of a 
fcrupleor more, has fucceededwithfeverals. 

such are, commonly, the methods of crtre delivered 
by Mr. Lieutaud, longiori et forte fdicijftma praxi edotlus. 

IT 



44 PREFACE. 

it would be tedious to enter further into that detail 
which a criticifm of this iramethodical and uninftructivc 
work might lead me into ; but, if the bounds proper for 
this preface did not prevent me, T would particularly 
fhew that the work is far from being free from thole i ea- 
fonings which the author pretends toavoid, and would af- 
fec"t even to delpile. He Hill holds the doctrines of the 
concoction and critical evacuation of morbif- 
ic matter ; doctrines depending upon fubtile theories, 
and which, in my opinion, can in nowife be ascertained 
as matters of fact. Mr. Lieutaud likev.ife is ftill very 
much upon the old plan of following nature, and there- 
fore gives often what I confider as a feeble and inert prac- 
tice. The humeel antra, diluentia, demulcentia, et temperan- 
tia, are with him very univerfal remedies, and often thofe 
which alone are to be employed. 

the mention of thefe medicines might lead me to take 
notice of Mr. Lieutaud's fecond volume, in which, ab in- 
fill a remediorum farragine alienus, he promifes a great ref- 
ormation upon the fubjeft ; but this falls fo far fhort of 
the idea of Britifh phyficians, that I need not make any 
remarks upon it. With refpecttohis lift of fimples, or 
Emporetica, asheispleafed to term them, anEnglifli apoth- 
ecary would fmile at it ; and with refpeft to his officinalia, 
I believe they are to be found no where but in the Codex 
Medicamentarius of Paris ; and in his Magiftralia his doles 
are generally fuch as the molt timid practitioner of this 
country would hardly defcend to, and fuch as none of our 
practitioners of experience would depend upon. In fhorr, 
the whole of the work, both with refpeel: to the theories 
with which it abounds, and to the fafts which it gives, 

Willi 



PREFACE- 45 

will not, in my apprehenfion, bear any ferious criticifm. 
But I muft conclude ; and fhall only fay further, that fuch 
as I have reprefented it, is this work, executed by a man 
of the firft rank in the profeflion. It is indeed for that 
reafon I have cho/en it as the example of a work, upon 
the plan of giving fads only, and of avoiding the ftudy or 
even the notice of the proximate caufes of difeafes ; and 
with what advantage fuch a plan is purfued, I lhall leave 
my readers to confider. 

in the following treatife I have followed a different 
courfe. I have endeavoured to collect the fails relative 
to the difeafes of the human body, as fully as the nature of 
the work and the bounds necefTarily prefenbed to it would 
admit : But 1 have not been fatisfied with'giving the fails, 
without endeavouring to apply them to the inveftigation 
of proximate caufes, and upon thefe to eftablifh a more 
fcientific and decided method of cure. In aiming at this, 
I flatter myfelf that I have avoided hypothefis, and what 
have been called theories. I have, indeed, endeavoured 
to eftablifh many general doitrines, both phyfiological ; 
and pathological ; but I truft that thefe are only a general- 
ifation of fails, or conclufions from a cautious and full 
induition ; and if any one fhall refufe to admit, or direilly 
fhall oppofe, my general doilrines, he muft do it by fhow- 
ing that I have been deficient or miftaken in afluming and 
applying fails. I have, myfelf, been jealous of my being 
fometimes imperfeil in thefe refpeils ; but I have gener- 
ally endeavoured to obviate the confequences of this, by 
proving, that the proximate caufes which I have afligned, 
are true in fail, as well as deductions from any reafonin°- 
that I may feem to have employed. Further, to obviate 
any dangerous fallacy in propofing a method of cure, I 

have 



iS PREFACE. 

have always been anxious to fuggeft that which, to the 
beft of my judgment, appeared to be the method approved 
of by experience, as much as it was the confequence of 
fvftem. 

upon this general plan I have endeavoured to form a 
fyftem of phyfic that fhould comprehend the whole of the 
fails relating to the fcience, and that will, I hope, collect 
and arrange them in better order than has been done be- 
fore, as well as point out in particular thole which are (till 
wanting to cftablifli general principles. This which I 
have attempted, may, like other fyftems, hereafter luffer 
a change ; but. I am confident that we are at prefent in a 
better train of inveftigation than phyficians were in before 
the time of Dr. Hoffman. The affections of the motions 
and moving powers of the animal economy, mutt certainly 
be the leading inquiry in confidering the difeafes of the hu- 
man body. The inquiry may be difficult ; but it muft be 
attempted, or the fubject muft be deferted altogether. I 
have, therefore, affumed the general principles of Hoff- 
man, as laid down in the paffage which I have quoted a. 
bove ; andif I have rendered them more correct, and more 
extenfive in their application ; and, more particularly, if 
I have avoided introducing the many hypothetical doc- 
trines of the Humoral Pathology which disfigured both 
his and all the other fyftems which have hitherto prevail- 
ed ; I hope I mail be excufed for attempting a iyftera, 
which upon the whole may appear new. 
Edinburgh, Nov. 1783. 



PART I. 

of PYREXIA, 

O R 

FEBRILE DISEASES. 




FIRST LINES 

OF THE 

PRACTICE of PHYSIC. 



I. 



N teaching the Practice 
of Physic, we endeavour 
to give inftru&ion for 
difccrning, dijlinguijhing, 
preventing, and curing dif- 
eafes, as they occur in par- 
ticular perfons. 

II. 



The art of d i sc e r n i n g and distinguish- 
ing diieafes, may be belt attained by an ac- 
C curate 




50 PRACTICE 

curate and complete observation of their phe- 
nomena, as thefe occur in concourfe and in 
fucceflion, and by conftantly endeavouring to 
diftinguifh the peculiar and infeparable con- 
currencc of fymploms, to eftablifh a Method- 
ical Nosology, or an arrangement of dif- 
eafes according to their genera and fpecies, 
founded upon obfervation alone, abftracled 
from all reafoning. Such an arrangement I 
have attempted in another work, to which in 
the courfe of the prefent I fhall frequently 
refer. 

III. 

The Prevention of difeafes depends 
upon the knowledge of their remote caufes ; 
which is partly delivered in the general Pa- 
thology, and partly to be delivered in this 
treatife. 

IV. 

The Cure of difeafes is chiefly, and al- 
moft unavoidably, founded in the knowledge 
of their proximate caufes. This requires an 
acquaintance with the Inflitutions of Medi- 
cine ; that is, the knowledge of the ftrufture, 
action, and functions of the human body ; 
of the feveral changes which it may undergo ; 
and of the feveral powers by which it can 
te changed. Our knowledge of thefe par- 
ticulars, 



OF PHYSIC. 51 

ticulars, however, is ftill incomplete, is in 
many refpe&s doubtful, and has been often 
involved in miftake and error. The doc- 
trine, therefore, of proximate caufes, founded 
upon that knowledge, muft be frequently pre- 
carious and uncertain. It is, however, pofli- 
ble for a judicious phyfician to avoid what is 
vulgarly called theory, that is, all reafoning 
founded upon hypothefis, and thereby many 
of the errors which have formerly taken 
place in the Inflitutions of Medicine. It is 
poflTtble alfo for a perfon who has an extenfive 
knowledge of the fa&s relative to the animal 
economy in health and in ficknefs, by a cau- 
tious and complete induction, to eftablifh 
many general principles which may guide his 
reafoning with fafety ; and while, at the fame 
time, a phyfician admits as a foundation of 
praclice thofe reafonings only which are fim- 
ple, obvious and certain, and for the mofl part 
admits as proximate caufes thofe alone that 
are eflablifhed as matters of fa6l rather than 
as deductions of reafoning, he may with great 
advantage eftablifh a fyftem of practice chiefly 
founded on the doftrine of proximate caufes. 
But when this cannot be done with fufficient 
certainty, the judicious and prudent phyfician 
will have recourfe to Experience alone ; 
always, however, aware of the hitherto in- 
complete and fallacious Hate of Empiricifm. 



C 2 V. 



52 PRACTIC E, &c. 



V. 



With a ftt'ift attention to thefe conftdera- 
tions in the whole of the following Treatife, 
I proceed to treat of particular difeafes in the 
order of my Methodical Nofology. 



PART 




Of 



uveccia&j ov 



if 



u f euvLi& zJJu&(zje4 . 



VI. 

,YREXIvE, or febrile difeafes, 
are diftmguifhed by the fol- 
lowing appearances. After 
beginning with fome degree 
of cold fhivering, they mow 
fome increafe of heat, and 
an increafed frequency of pulfe, with the in- 
terruption and diforder of feveral functions, 
particularly fome diminution of ftrength in 
the animal functions. 




VII. 

Of thefe Pyrexiae I have formed a clafs, 
and have fubdivided it into the live orders of 
Fevers, Inflammations, Eruptions, 
Hemorrhages, and Fluxes. See Synop- 
lis Nofologias Methodical, Edit. 3. 1780. 

C3 BOOK 



BOOK 



O F 



FEVERS. 



CHAP. I. 

of the PHENOMENA of FEVERS. 

VIII. 

xHOSE difeafes are more 
ftrittly called Fevers, which have the gen- 
eral fymptoms of pyrexia, without having 
alongft with them any topical affe&ion that is 
effential and primary, fuch as the other orders 
of the Pyrexias always have. 

IX. 

Fevers, as differing in the number and va- 
riety of their fymptoms, have been very prop- 
erly confidered as of diftincl: genera and fpe- 
cies. But we fuppofe, that there are certain 
circumftances in common to all the difeafes 
comprehended under this order, which are 
therefore thofe elfentially neceffary to, and 

properly 



OF PHYSIC. 55 

properly conftituting the nature of fever. It 
is our bufinefs efpecially, and in the firft place, 
to inveftigate thefe -, and I expeft to find them 
as they occur in the paroxyfm, or fit, of an in- 
termittent fever, as this is mofl commonly 
formed. 

X. 

The phenomena to be obferved in fuch a 
paroxyfm are the following. The perfon is 
affetted, firft, with a languor or fenfe of debil- 
ity, a fluggifhnefs in motion, and fome uneafi- 
nefs in exerting it, with frequent yawning and 
ftretching. At the fame time, the face and 
extremities become pale ; the features fhrink ; 
the bulk of every external part is diminifhed ; 
and the fkin, over the whole body, appears 
conftricled, as if cold had been applied to it. 
At the coming on of thefe fymptoms, fome 
coldnefs of the extremities, though little taken 
notice of by the patient, may be perceived by 
another perfon. At length, the patient him- 
felf feels a fenfation of cold, commonly firft in 
his back, but, from thence, palling over the 
whole body ; and now his fkin feels warm to 
another perfon. The patient's fenfe of cold 
increafing, produces a tremor in all hislimbs± 
with frequent fucceflions or rigors of the 
trunk of the body. When this fenfe of cold, 
and its effe&s, have continued for fome time, 
they become lefs violent, and are alternated 
with warm flufhings. By degrees, the cold 
C 4 goes 



56 PRACTICE 

goes off entirely ; and a heat, greater than 
natural, prevails, and continues over the 
whole body. With this heat, the colour of 
the lkin returns, and a preternatural rednefs 
appears, efpecially in the face. Whilft the 
heat and rednefs come on, the ikin is relaxed 
and fmoothed, but, for fome time, continues 
dry. The features of the face, and other 
parts of the body, recover their ufual lize, and 
become even more turgid. When the heat, 
rednefs, and turgefcence have increafed and 
continued for fome time, a moifture appears 
upon the forehead, and by degrees becomes a 
(treat, which gradually extends downwards 
over the whole body. As this fweat contin- 
ues to flow, the heat of the body abates ; the 
fweat, after continuing fome time, gradually 
ceafes ; the body returns to its ufual tempera- 
ture ; and moft of the functions are reftored to 
their ordinary flate. 

This feries of appearances gives occafion 
to divide the paroxyfm into three different 
flages ; which are called the Cold, the Hot, 
and the Sweating Stages or Fits. 

In- the courfe of thefe, confiderable changes 
happen in the flate of feveral other functions, 
which are now to be mentioned. 

XII. 

Upon the firft approach of languor, the 
pulfe becomes fome times flower, and always 

weaker 



OF PHYSIC. 57 

weaker than before. As the feirfe of cold 
comes on, the pulfe becomes fmaller, very 
frequent, and often irregular. As the cold 
abates, and the heat comes on, the pulfe be- 
comes more regular, hard, and full ; and in 
thefe refpe&s, increafes till the fweat breaks 
out. As the fweat flows, the pulfe becomes 
fofter, and lefs frequent, till the fweat ceafmg 
altogether, it returns to its ufual flatc 

XIII. 

The refpiration alfo fuffers fome changes; 
During the cold flage, the refpiration is fm.ill,. 
frequent, and anxious, and is fometimes at- 
tended with a cough ; as the hot (lage comes 
on, the refpiration becomes fuller and more 
free ; but continues flill frequent and anxious, 
till the flowing of the fweat relieves the anxi- 
ety, and renders the breathing lefs frequent and 
more free. With the ceafmg of the fweat, the 
breathing returns to its ordinary ftate. 

XIV. 

The natural functions alfo fufFer a change. 
Upon the approach of the cold flage, the ap- 
petite for food ceafes, and does not return till 
the paroxyfm be over, or the fweat has flowed 
for iome time. Generally, during the whole 
of the paroxyfm, there is not only a want of 
appetite, but an averfion from all folidj and 
ially animal food. As the cold flage ad- 
C 5 Tanccs, 



58 PRACTICE 

varices, there frequently comes on aficknefs and 
naufea, which often increafe to a vomiting of 
a matter that is for the moll part bilious. This 
vomiting commonly puts an end to the cold 
ftage, and brings on the hot. As the hot ftage 
advances, the naufea and vomiting abate ; and 
when the fweat breaks out, they generally ceafe 
altogether. 

XV. 

A confiderable degree of thirfl is common- 
ly felt during the whole courfe of the parox- 
yfm. During the cold ftage, the thirfl feems 
to arife from the drynefs and clamminefsof the 
mouth and fauces ; but, during the hot ftage, 
from the heat which then prevails over the 
whole body ; and, as the fweat flows, the 
mouth becomes moifter, and the thirft, togeth- 
er with the heat, gradually abates. 

XVI. 

In the courfe of a paroxyfm, there is often 
a confiderable change in the ftate of the fe- 
cretions. The circumftances juft now men- 
tioned fhow it in the fecretion of the faliva 
and mucus of the mouth ; and it is dill more 
remarkable with refpecl to the urine. Dur- 
ing the cold ftage, the urine is almoft colour- 
lefs, and without cloud or fediment. In the 
hot ftage, it becomes high coloured, but is 
flill without fediment. After the fweat has 

flowed 



OF PHYSIC. 59 

flowed freely, the urine depofites a fediment, 
commonly lateritious, and continues to do fo- 
for fome time after the paroxyfm is over. 

XVII. 

Excepting in certain uncommon cafes which 1 
are attended throughout with a diarrhoea, 
ftools feldom occur till towards the end of a 
paroxyfm, when commonly a ftool happens, 
and which is generally of a loofe kind. 

XVIII. 

Analogous to thefe changes in the ftate of 
the fecretions, it frequently happens, that tu- 
mours fubfifting on the furface of the body, 
fuffer, during the cold ftage of fevers, a hid- 
den and confiderable detumefcence ; but gen- 
erally, though not always, the tumours return 
to theirformer lize during thefweating ftage. 
In like manner, ulcers are fometimes dried 
up during the cold ftage ; and return again to 
difcharge matter during the fweating ftage, or 
after the paroxyfm is over. 

XIX. 

Certain changes appear alfo in fenfation 
and thought. During the cold ftage, the 
fenfibility is often greatly impaired ; but when 
the hot ftage is formed,' the fenfibility is re- 
covered, and often confiderably increafed. 

C6 XX. 



60 PRACTICE 

XX. 

With refpeft to the intellectual functions, 
when the cold ftage comes on, attention and 
recollection become difficult, and continue 
more or lei's fo during the whole paroxyfm. 
Hence fome confufion of thought takes place, 
and often arifes to a delirium, which fometimes 
comes on at the beginning of the cold ftage, 
but more frequently not till the hot Itage be 
formed. 

XXL 

It belongs alfo to this place to remark that 
the cold ftage fometimes comes on with a drow- 
finefs and itupor, which often increafe to a 
degree that may be called comutofe, or apo- 
plectic. 

XXII. 

We have ftill to add, that fometimes, early 
in the cold ftage, a headach comes on ; but 
which, more commonly, is not felt till the hot 
ftage be formed, and then is ufually attended 
with a throbbing of the temples. The head- 
ach continues till the fweat breaks out ; but 
as this flows more freely, that gradually goes 
off. At the fame time with the headach, 
there are commonly pains of the back, and 
of fome of the great joints ; and thefe pains 
have the fame courfe with the headach. 

XXIII. 



OF PHYSIC. 6i 



XXIII. 

Thefe are nearly the whole, and are at leafl 
the chief of the phenomena which more con- 
ftantly appear in the paroxyfm of an intermit- 
tent fever ; and we have pointed out their or- 
dinary concourfe and iucceffion. With re- 
fpeft to the whole of them, however, it is to 
be obferved, that, in different cafes, the feve- 
ral phenomena are in different degrees ; that 
the feries of them is more or lefs complete ; 
and that the feveral parts or ftages in the time 
they occupy, are in a different proportion to 
one another. 

XXIV. ' 

It is very feldom that a fever confifls of a 
fingle paroxyfm, fuch as we have now de- 
scribed ; and it more generally happens, after 
a certain length of time has elapfed from the 
ceafmg of the paroxyfm, that the fame feries 
of phenomena again arifes, and obferves the 
fame courfe as before ; and thefe ftates of Fe- 
ver and Apyrexia often continue to alter- 
nate with one another for many times. In 
fuch cafes, the length of time from the end of 
one paroxyfm to the beginning of another, is 
called an Intermission; and the length of 
time from the beginning of one paroxyfm to 
the beginning of another next fucceeding, is 
called an Interval. 

XXV. 



62 PRACTICE 



XXV. 

When the difeafe confifts of a number of 
paroxyfms, it is generally to be obferved; 
that the intervals between them are nearly 
equal ; but thefe intervals are of different 
lengths in different cafes. The molt ufual 
interval is that of forty eight hours, which is 
named the Tertian period. The next moft 
common is that of feventy two hours; and is 
named the Quartan period. Some other 
intervals alio are obferved, particularly one of 
twenty four hours, named therefore theQuo- 
tidian ; and the appearace of this is pretty 
frequent. But all other intervals longer than 
that of the quartan are extremely rare, and 
probably are only irregularities of the tertian 
or quartan periods.. 

XXVI. 

The ^paroxyfms of pure intermittent fevers 
are always finiftied in lefs than twenty four 
hours ; and though it happens that there are 
fevers which confift of repeated paroxyfms, 
without any entire intermiihon between them ; 
yet in fuch cafes it is obferved, that, though 
the hot and fweating ftages of the paroxyfm 
do not entirely ceafe before the twenty four 
hours from their beginning have expired, they 
fuffer, however, before that time, a conlider- 
able abatement or Remission of their vio- 
lence ; 



OF PHYSIC. 63 

lence ; and, at the return of the quotidian pe- 
riod, a paroxyfm is in fome fhape renewed, 
which runs the fame courfe as betore. This 
conftitutes what is called a Remittent 
Fever. 

XXVII. 

When in thefe remittents the remifTion is 
confiderable, and the return of a new parox- 
yfm is diftinctly marked by the fymptoms of 
a cold flage at the beginning of it ; fuch fe- 
vers retain ftricUy the appellation of Re- 
mittents. But when it happens, as it does 
in certain cafes, that the remiffion is not con- 
fiderable, is perhaps without fweat, and that 
the returning paroxyfm is not marked by the 
moft ufual fymptoms of a cold flage, but 
chiefly by the aggravation or Exacerba- 
tion of a hot flage, the difeafe is called a 
Continued Fever. 

XXVIII. 

In fome cafes of continued fever, the re- 
miflions and exacerbations are fo inconfider- 
abJe as not to be eafily obferved or diflin- 
guifhed ; and this has led phyficians to imag- 
ine, that there is a fpecies of fever fubfifling 
for feveral days together, and feemingly con- 
fining of one paroxyfm only. This they 
have called a Continent Fever ; but, in 
a long courfe of practice, I have not had an 
opportunity of obferving fuch a fever. 

XXIX. 



64 P R A C T I C I. 

XXIX. 

It is, however, to be obferved here, that 
the fevers of a continued form are to be dif- 
tinguifhed from one another ; and th;;!, while 
fome of a very continued form do (till belong 
to the feclion of intermittents > there are oth- 
ers which, though Hill confiding of feparate 
and repeated paroxyfms, yet, as different by 
their caufes and circumftances from intermit- 
tents, are to be diftinguifhed from the whole 
of thefe, and are more flri6bly to be called and 
confidered as Continued. Such are moft 
of thofe which have been commonly fupr 
to be Continent ; and thofe which by moft 
writers have been fimply named Continu- 
ed ; and which term I have employed as the 
title of a feftion, to be diftinguifhed from that 
of Intermittent. 

I fhall here add the marks by which, in 
practice, thefe different continued fevers may 
be diftinguifhed from one another. 

Thofe fevers of a continued form, which, 
however, flill belong to the lection of Intcr- 
mittents, may be diftinguifhed by their hav- 
ing paffed from an intermittent or remittent 
form, to that of a continued ; by their mow- 
ing fome tendency to become intermittent, or 
at leaft remittent ; by their being known to 
have been occafioned by marfii miafmata ; 
and, for the moft part, by their having but 
one paroxylVn, or one exacerbation and re- 
miffion, in the courfe of twentv fouf 

On 



OF PHYSIC. 6 5 

On the other hand, Continued Fevers, to 
be more ftri&ly To called, may be diftinguifh- 
( d by their mowing little tendency to become 
intermittent or remittent in any part of their 
courfe, and efpecially after the firft week of their 
continuance ; by their being occafioned by hu- 
man contagion, at leaft by other caufes than 
the marfh miafmata ; and by their having pret- 
ty conftantly an exacerbation and remiffion 
twice in the courfe of every twenty four hours. 
In both cafes, the knowledge of the nature of 
the epidemic for the time prevailing, may have 
a great (hare in determining the nature of the 
particular fever. 

XXX. 

With refpecl: to the form, or Type, of fe- 
vers, this further may be obferved, That the 
quartan, while it has the longed interval, has, 
at the fame time, the longeft and mofl violent 
cold ftage ; but, upon the whole, the fhorteft 
paroxyfm : That the tertian, having a fliorter 
interval than the quartan, has, at the fame time, 
a lhorter and lefs violent cold ftage j but a 
longer paroxyfm : And, laftly, that the quo- 
tidian, with the fhortefl interval, has the leaft 
of a cold ftage, but the longeft paroxyfm. 

XXXI. 

The type of fevers is fometimes changed in 
their courfe. When this happens, it is gener- 
ally 



66 PRACTICE 

ally in the following manner : Both tertians 
and quartans change into quotidians, quotid- 
ians into remittents, and thefe la 11 become oft- 
en of the mofl continued kind. In all thefe 
cafes, the fever has its paroxyfms protracted 
longer than ufual, before it changes into a 
type of more frequent repetition. 

XXXII. 

From all this a prefumptkm arifes, that 
every fever confifts of repeated paroxyfms ; 
differing from others chiefly in the circum- 
ftances and repetition of the paroxyfms ; and, 
therefore, that it was allowable for us to take 
the paroxyfm of a pure intermittent as an ex- 
ample and model of the whole. 

CHAP. II. 

©f the Proximate Cause of FEVER. 
XXXIII. 

JL HE proximate caufe of fe- 
ver feems hitherto to have eluded the refearch 
of phyficians ; and I ihall not pretend to af- 
certain it in a manner that may remove every 
difficulty ; but I fhall endeavour to make an 
approach towards it, and fuch as, I hope, may 
be of ufe in conducting the practice in this 

difeafe ; 



OF PHYSIC. 6 7 

difeafe ; while at the fame time I hope to a- 
void leveral errors which have formerly pre- 
vailed on this fubje£r.. 

XXXIV. 

As the hot ftage of fever is fo conftantly 
preceded by a cold ftage, we prefume that 
the latter is the caufe of the former ; and, 
therefore, that the caufe of the cold itage is 
the caufe of all that follows in the courfe of 
the paroxyfm. See Boerh. Aph. 756. 

XXXV. 

To difcover the caufe of the cold flage of 
fevers, we may obferve, that it is always pre- 
ceded by flrong marks of a general debility 
prevailing in the fyftem. The fmallnefs and 
weaknefs of the pulfe, the palenefs and cold- 
nefs of the extreme parts, with the fhrinking 
of the whole body, fufficiently fhow that the 
a&ion of the heart and larger arteries is, for 
the time, extremely weakened. Together 
with this, the languor, inactivity, and debility 
of the animal motions, the imperfect fenfa- 
tionSj the feeling of cold, while the body is 
truly warm, and fome other fymptoms, all 
(how that the energy of the brain is, on this 
occafion, greatly weakened ; and I prefume, 
that, as the weaknefs of the attion of the heart 
can hardly be imputed to any other caufe, 
this weaknefs alfo is a proof of the diminifh- 
ed energy of the brain. 

XXXVI. 



68 PRACTICE 



XXXVI. 

I fliall hereafter endeavour to fliow, that 
the mod noted of the remote caufes of fever, 
as contagion, miafmata, cold, and fear, 
of a fedativc nature ; and therefore render it 
probable that a debility is induced. Li 
wife, when the paroxyfms of a fever have 
cealed to be repeated, they may again be re- 
newed, and are moft commonly renewjed by 
the application of debilitating powers. And, 
further, the debility which fub lifts in the ani- 
mal motions and other functions through the 
whole of fever, renders it pretty certain that 
fedative or debilitating powers have been ap- 
plied to the body. 

XXXVII. 

It is therefore evident, that there are three 
ftates which always take place in fever ; a ftate 
of debility, a ftate of cold, and a ftate of heat ; 
and as thel'e three ftates regularly and con- 
flan tly fucceed each other in the order we 
have mentioned them, it is prefumed that they 
are in the feries of caufe and cfFecl; with rc- 
fpecT; to one another. This we hold as a 
matter of facf, even although we ftiould not 
be able to explain in what manner or by what 
mechanical means thefe ftates feverally pro- 
duce each other. 

XXXVIII.. 



OF PHYSIC. 69 

XXXVIII. 

How the ftate of debility produces fome of 
the l'ymptoms of the cold ftage, may perhaps 
be readily explained ; but how it produces 
all of them, I cannot explain otherwife than 
by referring the matter to a general law of the 
animal economy, whereby it happens, that 
powers which have a tendency to hurt and 
deftroy the fyflem, often excite fuch motions 
as are fuited to obviate the effects of the nox- 
ious power. This is the vis medicatrix 
natur /E, fo famous in the fchools of phyfic ; 
and it fcems probable, that many of the mo- 
tions excited in fever are the effects of this 
power. 

XXXIX. 

That the increafed action of the heart and 
arteries, which takes place in the hot ftage of 
fevers, is to be confidered as an effort of the 
vis medicatrix nalura y has been long a com- 
mon opinion among phyficians ; and I am 
difpofed to affert, that fbme part of the cold 
ftage may be imputed to the lame power. I 
judge fo, becaufe the cold ftage appears to be 
univerfaily a means of producing the hot ; 
becaufe cold, externally applied, has very 
often fimilar cffe£ts ; and more certainly ftill, 
becaufe it feems to be in proportion to the 
degree of tremor in the cold ftage, that the 
hot ft;ige proceeds more or lefs c^ickly to a 

tc. nination 



70 PRACTICE 

termination of the paroxyfm, and to a more 
complete folution and longer intermiflion. 
See XXX. 

XL. 

It is to be particularly obferved, that, dur- 
ing the cold ftage of fever, there feems to be a 
fpafm induced every where on the extremi- 
ties of the arteries, and more efpecially of 
thofe upon the furface of the body. This ap- 
pears from the fuppreffion of all excretions, 
and from the fhrinking of the external parts ; 
and although this may perhaps be imputed, 
in part, to the weaker aclion of the heart in 
propelling the blood into the extreme veffels; 
yet, as thefe fymptoms often continue after 
the aclion of the heart is reftored, there is 
reafon to believe, trat a fpafmodic conftric- 
tion has taken place ) that it fubfifls for fome 
time, and fupports the hot ftage ; for this ftage 
ceafes with the flowing of the fweat, and the 
return of other excretions, which are marks 
of the relaxation of veffels formerly conftri6l- 
ed. Hoffman. Med. rat. Syftem. Tom. IV. 
P. I. Sed. I. Cap. I. art. 4. 

XLI. 

The idea of fever, then, may be, that a 
fpafm of the extreme veffels, however induc- 
ed, proves an irritation to the heart and ar- 
teries ; and that this continues till the fpafm 
is relaxed or overcome. There are many 
appearances which iupport this opinion ; and 

there 



OF PHYSIC. 71 

there is little doubt that a fpafm does take 
place, which proves an irritation to the heart, 
and therefore may be confidered as a princi- 
pal part in the proximate caufe of fever. It 
will f till, however remain a queflron, what is 
the caufe of this fpafm ; whether it be direct- 
ly produced by the remote caufe of fever, or 
if it be only a part of the operation of the 
vis medicatrix nature. 

XLII. 

I am difpofed to be of the latter opinion, 
becaufe, in the Jirjl place, while it remains 
Hill certain that a debility lays the foundation 
of fever, it is not obvious in what manner the 
debility produces the fpafm, and, what feems 
to be its effea, the increafed aftion of the 
heart and arteries ; and, fccondly, becaufe, in 
almoft all the cafes in which an effort is made 
by the vis medicatrix natures, a cold fit and a 
fpafm of the extreme veffels are almoft always 
the beginnings of fuch an effort. See Gaub. 
Pathol. Medicin. art. 750. 

XLIII. 

It is therefore prefumed, that fuch a cold 
fit and ipafm at the beginning of fever, is a 
part of the operation of the vis medicatrix , 
but, at the fame time, it feems to me proba- 
ble, that, during the whole courfe of the fe 
ver, there is an atony fubfifW in the ex 
treme v C Sds t and that the relaxation of the 

fpafm 



72 PRACTICE 

fpafm requires the rcftoring of the tone and 
a&ion of thefe. 

XLIV. 

This it may be difficult to explain ; but 
I think it may be afcertained as a fa&, by the 
confideration of the fymptoms which take 
place with refpeft to the fun&ions of the 
itomach in fevers, fuch as the anorexia, nau- 
fea, and vomiting. (XIV.) 

From many circumftances it is fufficiently 
certain, that there is a confent between the 
itomach and furface of the body ; and in all 
cafes of the confent of diftant parts, it is pre- 
lumed to be by the connexion of the nervous 
iyftem, and that the confent which appears is 
between the fentient and moving fibres of the 
one part with thofe of the other ; is fuch, that 
a certain condition prevailing in the one part 
occafions a fimilar condition in the other. 

In the cafe of the ftomach and furface of 
the body, the confent particularly appears by 
the connexion which is obferved between the 
flate of the perfpiration and the ftate of the ap- 
petite in healthy perfons ; and if it may be 
prefumed that the appetite depends upon the 
ftate of tone in the mufcular fibres of the 
ftomach, it will follow, that the connexion 
of appetite and perfpiration depends upon a 
confent between the mufcular fibres of the 
flomach and the mufcular fibres of the extreme 
velTels, or of the organ of perfpiration, on the 
the furface of the body. 

4* 



OF P H Y S I C. 



/ o 



It is further in proof of the connexion be- 
tween the appetite and perfpiration, and at the 
fame time of the circumftances on which it 
depends, that cold applied to the furface of 
the body, when it does not flop perfpiration, 
but proves a ftimulus to it, is always a power- 
ful means of exciting appetite. 

Having thus eftabliihed the connexion or 
confent mentioned, we argue, that as the 
fymptoms of anorexia, naufea, and vomiting, 
in many cafes, manifeftly depend upon a flate 
of debility or lofs of tone in the mufcular fibres 
of the flomach ; fo it may be prefumed, that 
thefe fymptoms, in the beginning of fever, de- 
pend upon an atony communicated to the 
mufcular fibres of the ftomach from the muf- 
cular fibres of the extreme vefTels on the 
furface of the body. 

That the debility of the ftomach which 
produces vomiting in the beginning of fe- 
vers aclually depends upon an atony of the 
extreme veflels on the furface of the body, 
appears particularly from a faft obferved by 
Dr. Sydenham. In the attack of the plague, 
a vomiting happens, which prevents any med- 
icine from remaining on the flomach ; and 
Dr. Sydenham tells us, that in fuch cafes he 
could not overcome this vomiting but by ex- 
ternal means applied to produce a fweat ; that 
is, to excite the action of the veflels on the 
furface of the body. 

The fame connexion between the flate of 

the flomach and that of the extreme veflels 

D on 



74 PRACTICE 

on the furface of the bod)-, appears from this 
aJfo, that the vomiting, which fo frequently 
happens in the cold fiage of fevers, commonly 
ceafes upon the coming on of the hot, and very 
certainly upon any fweat's coming out (XIV.) 
It is indeed probable, that the vomiting in 
the cold flage of fevers, is one of the means 
employed by nature for refloring the deter- 
mination to the furface of the body ; and it is 
a circumftance affording proof, both of this, 
and of the general connexion between the 
flomach and furface of the body, that emetics 
thrown into the flomach, and operating there, 
in the time of the cold ilage, commonly put 
an end to it, and brino; on the hot flage. 

It alio affords a proof of the fame connex- 
ion, that cold water taken into the flomach 
produces an increafe of heat on the furface 
of the body, and is very often a convenient 
i.nd effectual means of producing fweat. 

From the whole we have now laid on this 
fubje£l, I think it is fufficiently probable, that 
the fymptoms of anorexia, naufea, and vomit- 
ing, depend upon, and are a proof of, an atony 
fubfi fling in the extreme veifels on the furface 
of the body ; and that this atony therefore, 
now afcertained as a matter of fa6t, may be 
ccnfidered as a principal circumflance in the 
proximate caufe of fever. 

XLV. 

This atony we fuppofe to depend upon a 
diminution of the energy of the brain ; and 

that 



OF PHYSIC. 75 

that this diminution takes place in fevers, we 
conclude, not only from the debility prevail- 
ing in fo many of the functions of the body, 
mentioned above (XXXV.) but particularly 
from fymptoms which are peculiar to the brain 
itfelf. Delirium is a frequent fymptom of 
fever ; and as from the phyfiology and pathol- 
ogy we learn that this fymptom commonly 
depends upon fome inequality in the excite- 
ment of the brain or intellectual organ ; we 
hence conclude, that, in fever, it denotes fome 
diminution in the energy of the brain. De- 
lirium, indeed, feems often to depend upon 
an increafed impetus of the blood in the vef- 
fels of the brain, and therefore attends phren- 
itis. It frequently appears alfo in the hot 
ftage of fevers, accompanied with a headach 
and throbbing of the temples. But as the 
impetus of the blood in the veffels of the head 
is often confiderably increafed by exercife, ex- 
ternal heat, paflions, and other caufes, without 
occafioning any delirium ; fo, fuppofmg that 
the fame impetus, in the cafe of fever, produces 
delirium, the reafon rauft be, that, at the fame 
time, there is fome caufe which diminifhes the 
energy of the brain, and prevents a free com- 
munication between the parts concerned in 
the intellectual functions. Upon the lame 
principles alfo, I fuppofe there is another fpe- 
cies of delirium, depending more entirely on 
the diminiihed energy of the brain, and which 
may therefore arife when there is no unufual 
increafe of the impetus of the blood in the 
D 2 velle'is 



?6 PRACTICE 

vefTelscf the brain. Such feems to be the de- 
ram occurring at the beginning of the cold 
ilage of fevers, or in the hot ftage of fuch fe- 
vers as mow ftrong marks of debility in the 
whole fyftem. 

XLVI. 

Upon the whole, our doflrine of fever is 
explicitly this. The remote caufes (XXXVI.) 
are certain fedative powers applied to the 
nervous fyftem, which diminishing the energy 
of the brain, thereby produce a debility in 
the whole of the functions (X X XV.) and par- 
Ucularlv in the aftion of the extreme veffels 
(XLIII.) (XLIV.) Such, however, is, at 
the fame time, the nature of the animal econ- 
omy (XXXVIII.) that this debility proves an 
indirect ftimuLus to the fanguiferous fyftem ; 
v hence, by the intervention of the cold ftage, 
fpaim connected with it (XXXIX. XL.) 
the action of the heart and larger arteries is in- 
creafed (XL.) and continues fo (XLI.) till it 
his had the effecl: of reftoring the energy of 
the brain, of extending this energy to the ex- 
treme veffels, of reftoring therefore their a£tion, 
and thereby efpecially overcoming the fpafm 

(ling them ; upon the removing of which, 
the exertion of fweat, and other marks of the 
n of excretories, take place. 

XLVII. 

This doctrine will, as I fuppofe, ferve to 
explain not only the nature of fever in gen- 
eral, 



OF PHYSIC. 7y 

eral, but alfo the various cafes of it which oc- 
cur. Before proceeding, however, to this, it 
may be proper to point out the opinions, and, 
as I apprehend, the miftakes, which have 
formerly prevailed on this fubjecl. 

XLVIII. 

It has been fuppofed that a lentor or vifcid- 
ity prevailing in the mafs of blood, and ft 
nating in the extreme veffels, is the caufe 
the cold ftage of fevers and its confequences. 
But there is no evidence of any fuch vifcidity 
previoufly fubfifling in the fluids ; and as it 
is very improbable that fuch a ftate of them 
can be very quickly produced, fo the fudden- 
nefs with which paroxyfms come on, renders 
it more likely that the phenomena depend up- 
on fome caufe acting upon the nervous fyftem, 
or the primary moving powers of the animal 
economy. See Van Swieten apud Boerh. 
Aph. 755. 

XLIX. 

Another opinion, which has been almoft 
uniyerfally received, is, that a noxious mat- 
ter introduced into or generated in the body, 
is the proximate caufe of fever ; and that the 
increafed action of the heart and arteries, 
which forms fo great a part of the difeafe, is an 
effort of the vismedicatrix natures to expel this 
morbific matter; and particularly to change 
D o or 



78 PRACTICE 

or concocl: it, fo as to render it either alto- 
gether innocent, or, at leaft, fit for being more 
eafily thrown out of the body. This doc- 
trine, however, although of as great antiquity 
as any of the records of phyfic now remain- 
ing, and although it has been received by al- 
mofl every fchool of medicine, yet appears to 
me to reft upon a very uncertain foundation. 
There are fevers produced by cold, fear, and 
other caufes, accompanied with all the eifen- 
tial circumftances of fever, and terminating 
by fweat ; but, at the fame time, without any 
evidence or fufpicion of morbific matter. 

There have been fevers fuddenly cured by 
a hemorrhagy, fo moderate as could not car- 
ry out any confiderable portion of a matter 
diffufed over the whole mafs of blood ; nor 
can we conceive how the morbific matter 
could be collected or determined to pals off 
by fuch an outlet as in that cafe is opened. 

Even fuppofmg a morbific matter were 
prefent, there is no explanation given in what 
manner the concoftion of it is performed ; 
nor is it fhown that any fuch change does in 
facl take place. In certain cafes, it is indeed 
evident, that a noxious matter is introduced 
into the body, and proves the caufe of fever ; 
but, even in thefe cafes, it appears that the 
noxious matter is thrown out again, without 
having fufFered any change ; that the fever 
often terminates before the matter is expelled ; 
and that, upon many occafions, without wait- 
ing the fuppofed time of concoQion, the fe- 
ver 



OF PHYSIC. 79 

ver can be cured, and that by remedies which 
do not feem to operate upon the fluids, or to 
produce any evacuation. 

L. 

While we thus reafon againft the notion of 
fever being an effort of nature, for concoct- 
ing and expelling a morbific matter ; I by no 
means intend to deny that the caufe of fever 
frequently operates upon the fluids, and par- 
ticularly produces a putrefcent ftate of them. 
I acknowledge that this is frequently the cafe ; 
but, at the fame time, I maintain, that fuch 
a change of the fluids is not commonly the 
caufe of fever ; that verv often it is an effeft 
only ; and that there is no reafon to believe 
the termination of the fever to depend upon 
the expulfion of the putrid matter. 

LI. 

Another opinion which has prevailed, re- 
mains ftill to be mentioned. In intermittent 
fevers, a great quantity of bile is commonly 
thrown out by vomiting ; and this is fo fre- 
quently the cafe, that many have fuppofed an 
unufual quantity of bile, and perhaps a pecu- 
liar quality of it, to be the caufe of intermit- 
tent fevers. This, however, does not appear 
to be well founded. Vomiting, bv whatever 
means excited, if often repeated with violent 
ftraining, feems to be powerful in emulging 
D 4 the 



So PRACTICE 

the biliary duels, and commonly throws out 
a great deal of bile. This will happen efpe- 
ciaiiy in the cafe of intermittent fevers. For 
as, in the Itate of, debility and cold flage of 
thefe fevers, the blood is not propelled in the 
ufual quantity into the extreme veffels, and 
particularly into thole on the furface of the 
body, but is accumulated in the veffels of the 
internal parts, and particularly in the vena 
portarum ; fo this may occafion a more copi- 
ous fecretion of bile. 

Thefe confiderations will, in fome meafure, 
account for the appearance of an unufual 
quantity of bile in intermittent fevers ; but 
the circumflance which chiefly occafions the 
appearance of bile in thefe cafes, is the influ- 
ence of warm climates and feafons. Thefe 
leldom fail to produce a flate of the human 
body, in which the bile is difpofed to pafs ofF, 
by its fecretories, in greater quantity than 
ufual ; and perhaps alfo changed in its quality, 
as appears from the difeafe of cholera, which 
fo frequently occurs in warm feafons. At the 
fame time, this difeafe occurs often without 
fever ; and we fhall hereafter render it fuf- 
ficiently probable, that intermittent fevers, 
for the mofl part, arife from another caufe, 
that is, from marlh effluvia ; while, on the 
other hand, there is no evidence of their 
arifing from the flate of the bile only. The 
marih effluvia, however, commonly operate 
mofl powerfully in the fame feafon that 
produces the change and redundance of the 

bile ; 



OF PHYSIC 81 

bile ; and therefore,- confided ng the vomit- 
ing, and other circumftances of the intermit- 
tent fevers which here concur, it is not l'ur- 
prifmg that autumnal intermittents are fo ott- 
en attended with effufions of bile. 

This view of the fubjeft does not lead us 
to confider the Hate or the bile as the caufe 
of intermittents, but merely as a circumftance 
accidentally concurring with them, from the 
ftate of the feafon in which they arife. What 
attention this requires in the conduft of the 
difeafe, I fhall confider hereafter. 

LI I. 

From this view of the principal hypothefes 
which have hitherto been maintained with 
refpecl to the proximate caufe of fever, it 
will appear, that fevers • do not arife from 
changes in the ftate of the fluids ; but that, 
on the contrary, almoft the whole of the phe- 
nomena of fevers lead us to believe that they 
chiefly depend upon changes in the ftate of 
the moving powers of the animal fyflem. 
Though we fhould not be able to explain all 
the circumftances of the difeafe, it is at lead 
of fome advantage to be led into the proper 
train of inveftigation. I have attempted to 
purfue it ; and-fhall now endeavour to apply 
the doftrine already delivered, towards ex- 
plaining the diverlity of fevers. 

*4lKC£IAP. 
D 



82 PRACTICE 



CHAP. III. 

of the DIFFERENCE of FEVERS, 
and its CAUSES. 

LIII. 

To afcertain the difference of 
fevers, I think it neceffary to obferve, in the 
firfl place, that every fever of more than one 
day's duration confifts of repeated, and in fome 
meafure feparate, paroxyfms ; and that the 
difference of fevers taken notice of above 
(from XXV. to XXX.) appears to confift in 
the different Mate of paroxyfms, and in the 
different circumftances of their repetition. 

LIV. 

That fevers generally confift of diflinct., 
and in fome meafure feparately repeated, par- 
oxyfms, I have alleged above to be a mat- 
ter of fa£t. ; but I mail here endeavour to 
confirm it, by affigning the caufe. 

LV. 

In every fever, in which we can diflm&ly 
obferve any number of feparate parox- 
yfms, we conflantly find that each parox- 
yfm is finifhed in lefs than twenty four hours ; 
but as I cannot perceive any thing in 
L M the 






OF PHYSIC. 83 

the caufe of fevers determining to this, I 
mull prelume it to depend on iome general 
law of the animal economy. Such a law 
feems to be that which fubje&s the economy, 
in many refpe&s, to a diurnal revolution. 
Whether this depends upon the original con- 
formation of the body, or upon certain pow- 
ers conftantly applied to it, and inducing a 
habit, I cannot pofitively determine ; but the 
returns of fleep and watching, of appetites 
and excretions, and the changes which regu- 
larly occur in the Hate of the pulfe, (how fuf- 
ficiently, that in the human body a diurnal 
revolution takes place. 

LVI. 

It is this diurnal revolution which, I fup~ 
pofe, determines the duration of the parox- 
yfms of fevers ; and the conftant and uni- 
verfal limitation of thefe paroxyfms (as ob- 
ferved in LV.) while no other caufe of it can 
be affigned, renders it fufficiently probable 
that their duration depends upon, and is de- 
termined by, the revolution mentioned. And 
that thefe paroxyfms are connected with that 
diurnal revolution, appears further from this, 
that though the intervals of paroxyfms are dif- 
ferent in different cafes, yet the times oftheac- 
cefhon of paroxyfms are generally fixed to one 
time of the day ; fo that Quotidians come on 
in the morning, Tertians at noon, and Quar- 
tans in the afternoon. 

D 6 LVII.. 



84 PRACTICE 



LVII. 

It remains to be remarked, that as Ouar- 
tans and Tertians are apt to become Quo- 
tidians, thefe to pafs into the Mate of Remit- 
tents, and thefe laft to become Continued ; 
and that, even in the Continued form, daily- 
exacerbations and remiflions are generally to 
be obferved ; fo all this mows fo much the 
power of diurnal revolution, that when, in 
certain cafes, the daily exacerbations and re- 
miflions are with difficulty diflinguifhed, we 
may Hill prefume, that the general tendency 
of the economy prevails, that the difeafe Mill 
confifls of repeated paroxyfms, and, upon the 
whole, that there is no fuch difeafe as that 
which the fchools have called a Continent Fe- 
ver. I expect that this do&rine will be con- 
firmed by what I fhall fay hereafter concern- 
ing the periodical movements obferved in 
continued fevers. 

LVIII. 

It being thus proved, that every fever, of 
more than one day's duration, confifls of re- 
peated paroxyfms ; we in the next place, re- 
mark, that the repetition of paroxyfms de- 
pends upon the circumftances of the parox- 
yfms which have already taken place. From 
what was obferved in XXX. and XXXI. it 
appears, that the longer pavoxyfms are pro- 
traded, 



/ 



OF PHYSIC. 85 

tradted, they are the fooner repeated ; and, 
therefore, that the caufe of the frequent rep- 
etition is to be fought for in the caufe of the 
protraction of paroxyfms. 

LIX. 

Agreeably to what is laid down in XLVI. 
and to the opinion of moft part of phyfi- 
cians, I fuppofe, that, in every fever, there is a 
power applied to the body, which has a tenden- 
cy to hurt and deftroy it, and produces in it 
certain motions which deviate from the natural 
ftate ; and, at the fame time, in every fever 
which has its full courfe, I iuppofe, that, in 
confequence of the conftitution of the animal 
economy, there are certain motions excited, 
which have a tendency to obviate the effects of 
the noxious power, or to correct and remove 
them. Both thefe kinds of motion are con- 
fidered as conftituting the difeafe. 

But the former is perhaps ftrittly the mor- 
bid ftate, while the latter is to be confidered 
as the operation of the vis medicatrix naturae 
of falutary tendency, and which I fhall here- 
after call the reaction of the fyftem. 

LX. 

Upon the fuppofition that thefe two ftates 
take place in every paroxyfm of fever, it 
will appear to be chiefly in the time of the 
hot flage that the reaction operates in remov- 
ing 



86 PRACTICE 

ing the morbid ftate ; and therefore, as this 
operation fucceeds more or lefs quickly, the 
hot ftage of paroxyfms will be fhorter or 
longer. But as the length of paroxyfm depends 
chiefly upon the duration of the hot ftage, lo 
the longer duration of this and of paroxyfms, 
mull be owing either to the obftinacy of re- 
fiftance in the morbid Mate, or to the weak- 
nefs of the falutary reaction ; and it is prob- 
able that fometimes the one and fometimes 
the other of thefe circumflances takes place. 

LXI. 

It feems to be only by the ftate of the 
fpafm, that we can judge of the refiftance of 
the morbid ftate of fever : And with refpec~r. 
to this fpafm I obferve, that either the caufe 
exciting it may be different in different caf- 
es ; or, though the caufe fhould be the fame in 
different perfons, the different degree of 
irritability in each may give occafion to a 
greater or leffer degree of fpafm ; and there- 
fore, the reaction in fever being given, the con- 
tinuance of the hot ftage, and of the whole 
paroxyfm, may be longer or fhorter, according 
to the degree of fpafm that has been formed. 

LXII. 

One caufe of the obftinacy of fpafm in fe- 
vers may be ciearly perceived. In inflam- 
matory difeafes, there is a diathefis phlogiftica 
dm prevailing 



OF PHYSIC. 87 

prevailing in the body( and this diathefis we 
fuppofe to confift in an" increafed tone of the 
whole arterial fyftem. ) When, therefore,, 
this diathefis accompanies fever, as it fome- 
times does, it may be fuppofed to give oc- 
cafion to the febrile fpafm's being formed 
more ftrongly, and thereby to produce more 
protracted paroxyfms. Accordingly we find^ 
that all inflammatory fevers are of the con- 
tinued kind ; and that all the caufes of the 
diathefis phlogiftica have a tendency to change 
intermittent into continued fevers. Contin- 
ued fevers, then, being often attended with 
the diathefis phlogiftica, we conclude, that in 
many cafes, this is the caufe of their continued 
form., it' r /Vl'ttaM 

)H^I2~ ■ VTTT uu - 

LXlId. £j 

In many fevers, however, there is no evi- 
dence of any diathefis phlogiftica being pre- 
fent, nor of any other caufe of more confider- 
able fpafm ; and, in fuch cafes, therefore, we 
mufti mpute the protraction of paroxvfms, 
and the continued form of the fever, to the 
weaknefs of reaction. That this caufe takes 
place, we conclude from hence, that, in many 
cafes of fever, wherein the feparate paroxyfms 
are the longeft protracted, and the moft diffi- 
cultly obferved, we find the moft confiderable 
fymptoms of a general debility : And there- 
fore we infer, that, in fuch cafes, the protract- 
ed paroxyfms, and continued form, depend 
upon a weaker reaction ; owing either to the 

caufes 



88 PRACTICE 

caufes of debility applied having been of a more 
powerful kind, or from circumftances of the 
patient's conflitution favouring their opera- 
tion. 

LXIV. 

Upon thefe principles we make a ftep to- 
wards explaining in general, with fome prob- 
ability, the difference of fevers ; but muff 
own, that there is much doubt and difficulty 
in applying the do6lrine to particular cafes. 
It applies tolerably well to explain the different 
ftates of intermittents, as they are more pure- 
ly fuch, or as they approach more and more 
to the continued form : But feveral difficul- 
ties ftill remain with refpecl: to many circum- 
ftances of intermittents ; and more ftill with 
refpecl: to the difference of thofe continued 
fevers, which we have diftinguiftied in our 
Nofology as different from intermittents, and 
as more efpecially intitled to the appellation 
of Continued, (fee Syn. Nof. Meth. P. V. 
Ch. I. Seel. II.) and explained more fully 
above. 

LXV. 

From the view given (LXI 1 1, and LXIV.) 
of the caufes of the protraction of paroxyfms, 
and therefore of the form of Continued fevers, 
ftriclly fo called, it feems probable, that the 
remote caufes of thefe operate by occafioning 

either 



OF PHYSIC. 89 

cither a phlogiflic diathefis, or a weaker re- 
action ; for we can obferve, that the mod obvi- 
ous difference of continued fevers depends up- 
on the prevalence of one or other ofthefe dates. 

LXVI. 

Continued fevers have been accounted of 
great diverfity ; but phyficians have not been 
fuccefsful in marking thefe differences, or in 
reducing them to any general heads. The 
diftinctrons made by the ancients are not well 
underflood ; and, fo far as either they or the 
modern nofologifts have diftinguifhed contin- 
ued fevers by a difference of duration, their 
diftinctrons are not well founded, and do not 
apply in fuch a manner as to be of any ufe. 
We think it agreeable to obfervation, and to 
the principles above laid down (LXIII. 
LXIV.) to diftinguifh continued fevers ac- 
cording as they fhow either an inflammatory 
irritation, or a weaker reaction. 

LXVII. 

This diftinction is the fame with that of 
fevers into the Inflammatory and Ner- 
vous; the diftinction at prefent moft gen- 
erally received in Britain. To the firft, as a 
genus, I have given the name of Synocha ; 
to the fecond, that of Typhus; and, little ftu- 
dious whether thefe names be authorifed by the 
ancient ufe of the fame terms, I depend upon 

their 



9 o PRACTICE 

their being underftood by the characters an- 
nexed to them in our Nofology, which I ap- 
prehend to be founded on obfervation. 

LXVIII. 

By thefe characters I think continued fe- 
vers may in practice be diltinguifhed ; and if 
that be the cafe, the principles above laid 
down will be confirmed. 

LXIX. 

Befide thefe differences of continued fever, 
now mentioned, I am not certain of having 
obferved any other that can be confidered as 
fundamental. But the moft common form 
of continued fevers, in this climate, feems to 
be a combination of thefe two genera ; and 
I have therefore given fuch a genus a place 
in our Nofology, under the title of Synochus. 
At the fame time, I think that the limits be- 
tween the Synochus and Typhus will be with 
difficulty affigned ; and I am difpofed to be- 
lieve, that the Synochus arifes from the fame 
caufes as the Typhus, and is therefore only a 
variety of it. 

LXX. 

The Typhus feems to be a genus compre- 
hending feveral fpecies. Thefe, however, are 
not yet well afcertained by obfervation ; and 

in 



OF PHYSIC. 91 

in the mean time we can perceive that many 
of the different cafes obferveddo not imply any 
fpecific difference, but feem to be merely va- 
rieties, arifing from a different degree of power 
in the caufe, from different circumftances of 
the climate or feafon in which they happen, 
or from different circumftances in the confti- 
tution of the perfons affected. 

LXXI. 

Some of the effects arifing from thefe cir- 
cumftances require to be particularly explain- 
ed. 

One is, an unufual quantity of bile appear- 
ing in the courfe of the difeafe. This abun- 
dance of bile may poffibly attend fome con- 
tinued fevers, ftri&ly fo called ; but, for the 
reafons above explained, it more commonly 
attends intermittents, and, we believe, it might 
have been enumerated (XXIX.) among the 
marks diftinguifhing the latter kind of fevers 
from the former. But, though an unufual 
quantity of bile fhould appear with continued 
fevers, it is confidered in this cafe, as in that 
of intermittents, to be a coincidence only, ow- 
ing to the ftale of the feafon, and producing 
no different fpecies or fundamental diftinc- 
tion, but merely a variety of the difeafe. I 
think it proper to obferve here, that it is 
probable that the moft part of the continued 
fevers named Bilious have been truly fuch as 
belong to the fe&ion of Intermittents. 

LXXII. 



92 PRACTICE 

LXXII. 

Another effect: of the circumftances occa- 
fionally varying the appearance of typhus, is 
a putrefccnt ftate of the fluids. The an- 
cients, and likewife the moderns, who are in 
general much difpofed to follow the former, 
have diftinguifhed fevers, as putrid and non- 
putrid : But the notions of the ancients, on 
this fubjett, were not fufticiently correct to 
deferve much notice ; and it is only ol late that 
the matter has been more accurately obferv- 
ed, and better explained. 

From the diffolved ftate of the blood, as it 
prefents itfelf when drawn out of the veins, 
or as it appears from the red blood's being 
difpofed to be efFufed and run off by various 
outlets, and from feveral other fymptoms to 
be hereafter mentioned, I have now no doubt, 
how much focver it has been difputed by- 
fome ingenious men, that aputrefcency of the 
fluids to a certain degree does really take place 
in many cafes of fever. This putrefcency,. 
however, often attends intermittent, as well as 
continued fevers, and, of the continued kind, 
both the fynochus and typhus, and all of them 
in very different degrees ; fo that, whatever at- 
tention it may deferve in practice, there is no 
fixingr fuch limits to it as to admit of eflablifh- 

o 

ing a fpecies under the title of P u t r i d . 

LXXIII. 

Befide differing by the circumftances al- 
ready mentioned, fevers differ alfo by their 

being 



OF PHYSIC. 



93 



being accompanied with fymptoms which be- 
long to difeafes of *the other orders of pyrex- 
ias. This fometimes happens in fuch a man- 
ner, as to render it difficult to determine which 
of the two is the primary difeafe. Common- 
ly, however, it may be afcertained by the 
knowledge of the remote caufe, and of the 
prevailing epidemic, or by obferving the fe- 
ries and fucceflion of fymptoms. 

LXXIV. 

Moft of our fyftems ofphyfic have marked, 
as a primary one, a fpecies of fever under the 
title of Hectic ; but, as it is defcribcd, I 
have never feen it as a primary difeafe. I 
have conftantly found it as afymptom of fome 
topical affection, moft commonly of an inter- 
nal fuppuration ; and as fuch it mall be con- 
fxdered in another place. 

LXXV. 

The diftin&ion of the feveral cafes of inter-, 
mittent fever I have not profecuted here ; 
both becaufe we cannot affign the caufes of 
the differences which appear ; and becaufe I 
apprehend that the differences which in fact 
occur may be readily underftood from what is 
faid above (XXV. XXVI. and XXVII.) 
and more fully from our Methodical Nofolo- 
gy t CI. I. Sea. I. 

CHAP. 



94 PRACTICE 

CHAP. IV. 

of the REMOTE CAUSES of FEVER. 

LXXVI. 

AS fever has been held to 
confift chiefly in an increafed action of the 
heart and arteries, phyficians have fup- 
pofed its remote caufes to be certain direct 
flimulants fitted to produce this increafed ac- 
tion. In many cafes, however, there is no 
evidence of fuch ilimulants being applied ; 
and, in thofe in which they are applied, they 
either produce only a temporary frequency 
of the pulfe, which cannot be considered 
as a difeafe ; or, if they do produce a 
permanent febrile ftate, it is by the inter- 
vention of a topical inflammation, which pro- 
duces a difeafe different from what is ftrictly 
called fever. (VIII.) 

LXXVII. 

That direct, flimulants are the remote cauf- 
es of fever, feems farther improbable ; be- 
caufe the fuppofition does not account for 
the phenomena attending the acceflion of fe- 
vers, and becaufe other remote caufes can with 
greater certainty be affigned. 

LXXVIII. 



OF PHYSIC. 95 



LXXVIII. 

As fevers are fo generally epidemic, it is 
probable, that fome matter floating in the at- 
mofphere, and applied to the bodies of men, 
ought to be confidered as the remote caufe of 
fevers : And thefe matters prefent in the at- 
mofphere, and thus acting upon men, may be 
confidered, either as Contagions, that is, 
effluvia arifing dire&ly or originally from the 
body of a man under a particular difeafe, and 
exciting the fame kind of difeafe in the body 
of the perfon to whom they are applied ; or 
Mi asm at a, that is effluvia arifing from oth- 
er fubftances than the bodies of men, pro- 
ducing a difeafe in the perfon to whom they 
are applied. 

LXXIX. 

Contagions have been fuppofed to be of 
great variety ; and it is poflible this may be 
the cafe ; but that they truly are fo, does not 
appear clearly from any thing we know at 
prefent. The genera and fpecies of contagi- 
ous difeafes, of the clafs of Pyrexiae, at pref- 
ent known, are in number not very great. 
They chiefly belong to the order of Fevers, to 
that of Exanthemata, or that of Profluvia. 
Whether there be any belonging to the order 
of Phlegmafiac, is doubtful ; and though there 
fhould, it will not much increafe the number 

of 



9 6 PRACTICE 

of contagious pyrexiae. Of the contagious 
exanthemata and profluvia, the number of 
fpecies is nearly afcertained ; and each of 
them is fo far of a determined nature, that 
though they have now been obferved and dif- 
tinguifhed for many ages, and in many differ- 
ent parts of the world, they have been always 
found to retain the fame general character, 
and to differ only in circumftances, that may 
be imputed to fealon, climate, and other ex- 
ternal caufes, or to the peculiar conftitutions 
of the feveral perfons affecled. It feems, 
therefore, probable, that, in each of thefe fpe- 
cies, the contagion is of one fpecific nature ; 
and that the number of contagious exanthe- 
mata or profluvia is hardly greater than the 
number of fpecies enumerated in the fyftems 
of nofology. 

LXXX. 

If, while the contagious exanthemata and 
profluvia are thus limited, we mould fuppofe 
the contagious pyrexiae to be ftill of great 
and unlimited variety, it muft be with re- 
fpecl; to the genera and fpecies of continued 
fevers. But if I be right in limiting, as I have 
done, the genera of thefe fevers (LXVII. — 
LXX.) it will appear likely that the conta- 
gions which produce them arc not of great va- 
riety ; and this will be much confirmed, if we 
can render it probable that there is one prin- 
cipal, perhaps one common, fource of fuch 
contagion. 

LXXXI. 



OF PHYSIC. 97 

LXXXI. 

To this purpofe, it is now well known, that 
the effluvia conftantly arifing from the living 
human body, if long retained in the fame 
place, without being difFufed in the atmof- 
phere, acquire a fmgular virulence ; and, in 
that ftate, being applied to the bodies of men, 
become the caufe of a fever which is highly 
contagious. 

The exiftence of fuch a caufe is fully prov- 
ed by the late obfervations on jail and hof- 
pital fevers ; and that the fame virulent mat- 
ter may be produced in many other places, 
mull be fufficiently obvious : And it is prob- 
able that the contagion arifing in this manner 
is not, like many other contagions, perma- 
nent and conftantly exifting ; but that, in the 
circumftances mentioned, it is occasionally 
generated. At the fame time, the nature of 
the fevers from thence, upon different occa- 
fions, arifing, renders it probable that the 
virulent ftate of human effluvia is the com- 
mon caufe of them, as they differ only in a 
ftate of their fymptoms ; which may be im- 
puted to the circumftances of feafon, climate, 
S:c. concurring with the contagion, and mod- 
ifying its force. 

LXXXII. 

With refpecl to thefe contagions, though 
we have fpoken of them as of a matter float- 
ing in. the atmofphere, it is proper to obferve, 
E that 



98 PRACTICE 

that they are never found to act but when 
they are near to the fources from whence 
they arife ; that is, either near to the bodies 
of men, from which they immediately iffue ; 
or near to fome fubflances which, as having 
been near to the bodies of men, are imbued 
with their effluvia, and in which fubflances 
thefe effluvia are fometimes retained in an 
active ftate for a very long time. 

The fubflances thus imbued with an active 
and infectious matter, may be called Fomites ; 
and it appears to me probable, that contagi- 
ons, as they arife from fomites, are more pow- 
erful than as they arife immediately from the 
human body. 

LXXXIII. 

Miafmata are next to be confidered. Thefe 
may arife from various fources, and be of dif- 
ferent kinds ; but we know little of their va- 
riety, or of their feveral effects. We know 
with certainty only one fpecies of miafma, 
which can be confidered as the caufe of fe- 
ver; and, from the univerfality of this, it 
may be doubted if there be any other. 

LXXXIV. 

The miafma, fo univerfally the caufe of fe- 
ver, is that which arifes from marines or moifl 
ground, acted upon by heat. So many ob- 
ations have now been made with refpect to 

this, 



OF PHYSIC. 99 

this, in fo many different regions of the earth, 
that there is neither any doubt of its being in 
general a caufe of fevers, nor of its being very 
univerfally the caufe of intermittent fevers, 
in all their different forms. The fimilarity 
of the climate, ieafon, and foil, in the differ- 
ent countries in which intermittents arife, and 
the fimilarity of the difeafes, though arifing 
in different regions, concur in proving that 
there is one common caufe of thefe difeafes, 
and that this is the marfh miafma. 

What is the particular nature of this miaf- 
ma, we know not ; nor do we certainly know 
whether or not it differs in kind : But it is 
probable that it does not ; and that it varies 
only in the degree of its power, or perhaps as 
to its quantity, in a given fpace. 

LXXXV. 

It has been now rendered probable, that 
the remote caufes of fevers (VIII.) are chief- 
ly Contagions or Miafmata, and neither of 
them of great variety. We have fuppofed 
that miafmata are the caufe of intermittents, 
and contagions the caufe of continued fevers, 
ftri£tly fo named ; but we cannot with pro- 
priety employ thefe general terms. For, as 
the caufe of continued fevers may arife from 
fomites, and may, in fuch cafes, be called a 
Miafma ; and as other miafmata alfo may pro- 
duce contagious difeafes ; it will be proper to 
dillinguilh the caufes of fevers, by ufing the 
F 2 terms 



too PRACTICE 

terms Human or MarJJi Effluvia, rather than 
the general ones of Contagion or Miafma. 

LXXXVI. 

To render our doctrine of fever confiitent 
and complete, it is neceffary to add here, that 
thole remote caufes offerer, human and marfh 
effluvia, feen: to be of a debilitating or feda- 
tivc quality. They arife from a putrescent 
matter. Their production is favoured and 
their power increafed, by circumftances which 
favour putrefaction ; and they often prove 
putrefa6live ferments with refpect. to the ani- 
mal fluids. As putrid matter, therefore, is 
always, with refpefit to animal bodies, a pow- 
erful fedative, lb it can hardly be doubted 
that human and marfh effluvia are of the 
fame quality ; and it is confirmed by this, that 
the debility which is always induced, feems to 
be in proportion to the other marks that ap- 
pear of the power of thofe caufes. 

LXXXVII. 

Though we have endeavoured to fhow 
that fevers generally arife from marfh or hu- 
man effluvia, we cannot, with any certainty, 
exclude fome other remote caufes, which are 
commonly fuppofed to have at lead a fhare in 
producing thofe difeafes. And I proceed, 
therefore, to inquire concerning thefe caufes ; 
rft of which that merits attention is, the 
:cr of cold applied to the human body. 

LXXXVIII. 



OF PHYSIC. 101 

LXXXVIII. 

The operation of cold on a living body is 
fo different in different circumflances, as to 
be of difficult explanation ; it is here, there- 
fore, attempted with fome diffidence. 

The power of cold may be confidered as 
abfolute or relative. 

The abfolute power is that by which it can 
diminifh the temperature of the body to which 
it is applied. And thus, if the natural tem- 
perature of the human body is, as we fuppofe 
it to be, that of 98 degrees of Farenheit's ther- 
mometer * ; every degree of temperature lefs 
than that, may be confidered as cold with re- 
fpe6t to the human body ; and, in proportion 
to its degree, will have a tendency to diminifh 
the temperature of the body. But as the liv- 
ing human body has in itfelf a power of gen- 
erating heat, fo it can fuflain its own proper 
heat to the degree above mentioned, though 
furrounded by air or other bodies of a lower 
temperature than itfelf ; and it appears from 
obfervation, that, in this climate, air, or other 
bodies, applied to the living man, do not di- 
minifh the temperature of his bodv, unlefs the 
temperature of the bodies applied be below 62 
degrees. From hence it appears, that the ab- 
folute power of cold in this climate, does not 
E 3 a£t 

* In every inftance of our mentioning degrees of heat 
or cold, we fhall mention them by the degrees in Faren- 
heit's fcale ; and the expreflion of higher or lower fhall' 
always be according to that fcalc. 



102 PRACTICE 

acT: upon the living human body, unlefs the 
cold applied be below the degree jufl now- 
mentioned. 

It appears alio, that the human body's be- 
ing furrounded by air of a lower temperature 
than itfelf, is neceflary to its being retained in 
its proper temperature of 98 degrees ; for, in 
this climate, every temperature of the air 
above 62 degrees, applied to the human body, 
though Mill of a lower temperature than itfelf, 
is found to increafe the heat of it. And from 
all this it appears, that the abfolute power of 
cold with refpecl; to the human body, is very 
different from what it is with refpecl; to inan- 
imate bodies. 

LXXXIX. 

The relative power of cold with refpecl: to 
the living human body, is that power by which 
it produces a fenfation of cold in it ; and with 
refpecl; to this, it is agreeable to the general 
principle of fenfation, that the fenfation pro- 
duced, is not in proportion to the abfolute 
force of impreflion, but according as the new 
imprefhon is ftronger or weaker than that 
which had been applied immediately before. 
Accordingly, with refpecl; to temperature, the 
fenfation produced by any degree of this, de- 
pends upon the temperature to which the 
body had been immediately before expofed ; 
fo that whatever is higher than this feels warm, 
and whatever is lower than it feels cold ; and 

it 



O F P H Y S I C. 103 

it will therefore happen that the oppofite fen- 
fations of heat and cold may on different oc- 
cafions arife from the fame temperature, as 
marked by the thermometer. 

With refpecl; to this, however, it is to be 
obferved, that though every change of tem- 
perature gives a fenfation of cold or heat as it 
is lower or higher than the temperature ap- 
plied immediately before, the fenfation pro- 
duced is, in different cafes, of different dura- 
tion. If the temperature at any lime applied 
is under 62 degrees, every increafe of temper- 
ature applied will give a fenfation of heat ; but 
if the increafe of temperature does not arife to 
62 degrees, the fenfation produced will not 
continue long, but be foon changed to a fen- 
fation of cold. In like manner, any temper- 
ature, applied to the human body, lower than 
that of the body itfelf, gives a fenfation of 
cold ; but if the temperature applied does not 
go below 62 degrees, the fenfation of cold will 
not continue long, but be foon changed to a 
fenfation of heat. 

It will appear hereafter, that the effects of 
the fenfation of cold will be very different, ac- 
cording as it is more permanent or tranfitory. 

XC. 

Having thus explained the operation of cold 
as abfolute or relative with refpecl: to the hu- 
man body, I proceed to mention the general 
effects of cold upon it. 

E 4 1. Cold, 



104 PRACTICE 

1. Cold, in certain circumftances, has man- 
ifestly a fedative power. It can extinguifh 
the vital principle entirely, either in particu- 
lar parts, or in the whole body ; and confider- 
ing how much the vital principle of animals 
depends upon heat, it cannot be doubted that 
the power of cold is always more or lefs di- 
rectly fedative. 

This effe£t may be faid to take place from 
every degree of abfolute cold ; and, when the 
heat of the body Jias upon any occafion been 
preternaturally increafed, every lower temper- 
ature may be ufeful in diminifhing the activi- 
ty of the fyftem ; but it cannot diminifh the 
natural vigour of the vital principle, till the 
cold applied is under 62 degrees ; nor even 
then will it have this effect, unlefs the cold 
applied be of an intenfe degree, or be applied 
for fome length of time to a large portion of 
the body. 

2. It is equally manifeft, that, in certain 
circumftances, cold proves a Jlimulus to the 
living body, and particularly to the Sanguifer- 
ous fyftem. 

It is probable, that this effect: takes place 
in every cafe in which the temperature appli- 
ed produces a fenfation of cold ; and this, 
therefore, as depending entirely on the relative 
power of cold, will be in proportion to the 
change of temperature that takes place. 

It appears to me probable, that every change 
of temperature from a higher to a lower de- 
gree, will prove more or lefs flimulant ; ex- 
cepting 



OF P II Y S i C. 105 

neptihg when the cold applied is io intenfe, 
as immediately to extinguifti the vital princi- 
ple in the part. 

3. Be fide the fedative and ftimulant pow- 
ers of cold, it is manifeftly alfo a powerful 
ajtringenty caufing a contraction of the veffels- 
on the furface of the body, and thereby pro- 
ducing apalenefs of the fkin and a fuppreflion 
of perfpiration ; and it feems to have fimilar 
efFefts when applied to internal parts. It is 
likewife probable, that this conftri£r.ion, as it 
takes place efpecially in confequence of the 
fenfibility of the parts to which the cold is 
applied, will in fome meafure be communi- 
cated to other parts of the body- and that 
thereby the application of cold proves a tonic 
power with refpecl; to the whole fyftem. 

Thefc effects of tonic and aftringent power 
feem to take place both from the abfolute and 
relative power of cold ; and therefore every 
application of it which gives a fenfation of 
cold, is, in its firfl effect:, both aftringent and 
ftimulant, though the former may be oft- 
en prevented from being either confiderable or 
permanent when the latter immediately takes^ 
place. 

XCI. 

It will be obvious, that thefe feveral effects- 

of cold cannot all take place at the fame time,. 

but may in fucceffion be varioufiy combined.. 

The ftimulant power taking place obviates the' 

E 5 effects,. 



106 PRACTICE 

effects, at leaff. the permanency of the effects, 
that might otherwife have arifen from the le- 
dative power. That the fame ftimulant pow- 
er prevents thefe from the aftringent, I have 
faid above ; but the ftimulant and tonic pow- 
ers of cold are commonly, perhaps always, 
conjoined. 

XCII. 

Thefe general effe&s of cold now pointed 
out are fometimes falutary, frequently mor- 
bid j but it is the latter only I am to confider 
here, and they feem to be chiefly the follow- 

in s- 

1. A general inflammatory difpofition of 
the fyftem, which is^ commonly accompanied 
with Rheumatifm or other Phlegmafiae. 

2. The fame inflammatory difpofition ac- 
companied with Catarrh. 

3. A Gangrene of particular parts. 

4. A Palfy of a fingle member. 

5. A Fever, or Fever ftrictly fo called 
(VIII.) which it often produces by its own 
power alone, but more commonly it is only 
an exciting cautfe of fever by concurring with 
the operation (JHpman or marfh effluvia. 

te'xcni. 

Cold is often applied to the human body 
without producing any of thefe morbid ef- 
fects, and it is difficult to determine in what 

circumftances 



OF PHY S-^C. 107 

Gircumftances it efpecially operates in produc- 
ing them. It appears to me, that the morbid 
effects of cold depend partly upon certain 
circumftances of the cold itfelf, and partly on 
certain circumftances of the perfon to whom 
it is applied. 

XCIV. 



The circumftances of the cold applied,, 
which feem to give it efr'e£t, are, 1. The in^ 
tenfity or degree of the cold ; 2. The length 
of time during which it is applied ; 3. The 
degree of moifture at the fame time accom- 
panying it ; 4. Its being applied by a wind 
or current of air ; 5. Its being a viciflitude, or 
fudden and confiderable change of tempera- 
ture, from heat to cold.. 

xcv. 



The circumftances of perfons rendering 
them more liable to be affected by cold, feem< 
to be, 1. The weaknefs of the fyftem, and 
particularly the leftened vigour of the circula- 
tion, occafioned by falling,, by evacuations, 
by fatigue, by a laft night's debauch, by ex- 
cefs in venery, by long watching, by much 
ftudy, by reft immediately after great exer- 
cife, by fleep, and by preceding difeafe. 
2. The body, or its parts, being deprived of 
their accuftomed coverings. 3. One part 
E 6 of 



108 PRACTICE 

of the body being expofed to cold, while the 
reft is kept in its ufual or a greater warmth. 

XCVI. 

The power of thefe circumftances (XCV.) 
is demonftrated by the circumftances enabling 
perfons to refill cold. Thefe are a certain 
vigour of conftitution, exercife of the body, 
the prefencc of active paflions, and the ule of 
cordials. 

Befide thefe, there are other circumftances 
which, by a different operation, enable per- 
fons to refill cold a£lyig as a fenfation ; fuch 
as, paflions engaging a clofe attention to one 
object, the ufe of narcotics, and that ftate of 
the body in which fenfibility is greatly dimin- 
ished, as in maniacs. To all which is to be 
added, the power of habit with refpe£l to thofe 
parts of the body to which cold is more con- 
ftantly applied, which both diminifhes fenfi- 
bility and increafes the power of the activity 
generating heat. 

XCVII. 

Befide cold, there are other powers that; 
feem to be remote caufes of fever ; fuch as, 
fear, intemperance in drinking, excefs in ven- 
ery, and other circumftances, which evidently 
weaken the fyftem. But whether any of thefe 
fedative powers be alone the remote caufe of 
fever, or if they only operate either as concur- 
ring 



OF PHYSIC. 



109 



ring with the operation of marfh or human ef- 
fluvia, or as giving an opportunity to the ope- 
ration of cold, are queftions not to be pofitive- 
ly anfwered ; they may poffibly of themfelvea 
produce fever ; but mod frequently they ope- 
rate as concurring in one or other of the ways 
above mentioned. 

XCVIII, 

Having now mentioned the chief of the re- 
mote caules of fevers, it may be further ob- 
served, that thefe will arife more or lefs readi- 
ly, according as miafmata and contagions are 
more or lefs prevailing and powerful, or as 
thefe are more or lefs favoured by the con- 
currence of cold and other fedative powers. 

CHAP. V. 

©f the PROGNOSIS of FEVERS. 

XCIX. 

AS fevers (by LX.) confift 
of both morbid and falutary motions and 
fymptoms, the tendency of the difeafe to a 
happy or fatal iifue, or the prognoftic in fe- 
vers, has been eftablifhed by marking the 
prevalence of the morbid or of the falutary 
fymptoms j and it might be properly fo eftab- 

lifhed, 



no PRACTICE 

lifhed, if we could certainly diftinguifh between 
the one and the other of thefe kinds of fymp- 
toms ; but the operation of the reaction, or 
falutary efforts of nature in curing fevers, is 
ftill involved in fo much oblcurity, that I 
cannot explain the feveral fymptoins of it lb 
clearly as to apply them to the eftablifhing 
prognoflics ; and this, I think, may be done 
better, by marking the morbid fymptoms 
which fhow the tendency to death in fevers. 

C. 

This plan of the prognoflics in fevers muff 
proceed upon our knowledge of the caufes of 
death in general, and in fevers more particu- 
larly. 

The caufes of death, in general, are either 
direct or indirect. 

The firfl are thofe which directly attack and 
deftroy the vital principle, as lodged in the 
nervous fyftem ; or deftroy the organization 
of the brain immediately neceffary to the ac- 
tion of that principle. 

The fecond, or the indirect caufes of death, 
are thofe which interrupt fuch functions as 
are neceffary to the circulation of the blood, 
and thereby neceffary to the due continuance 
and fupport of the vital principle. 

CI. 

Of thefe general caufes, thofe which ope- 
rate more particularly in fevers feem to be, 



OF PHYSIC. |ii 

Jirft, The violence of reaction ; which either, by 
repeated violent excitements, deftroys the vital 
power itfelf ; or, by its violence, deftroys the 
organization of the brain neceflary to the ac- 
tion of that power ; or, by the fame violence, 
deftroys the organization of the parts more 
immediately neceflary to the circulation of 
the blood. 

Secondly> The caufe of death in fevers may 
be a poifon, that is, a power capable of de- 
ftroying the vital principle ; and this poifon 
may be either the miafma or contagion which 
was the remote caufe of the fever, or it may be 
a putrid matter generated in the courfe of the 
fever. In both cafes, the operation of fuch a 
power appears either as a6ling chiefly on the 
nervous fyftem, inducing the fymptoms of de- 
bility ; or as a&ing upon the fluids of the body, 
inducing a putrefcent ftate in them. 

CII. 

From all this it appears, that the fymptoms 
fhowing the tendency to death in fevers, may 
be difcovered by their being either the fymp- 
toms 

Of violent reaction ; 

Of great debility ; 

Or, of a Jlrong tendency to putrefaction in 
the fluids. 

And upon this fuppofition, I proceed now 
to mark thofe fymptoms more particularly. 

cm. 



ff£ PRACTICE 



cur. 

The fymptoms which denote the violence of 
reaction, are, 1 . The increafed force, hardnefs, 
and frequency of the pulfe. 2. The increafed 
heat of the body. 3. The fymptoms which 
are the marks of a general inflammatory dia- 
thefis, and more efpecially of a particular de- 
termination to the brain, lungs, or other im- 
portant vifcera. 4. The fymptoms which are 
the marks of the caufe of violent reaction ; that 
is, of a ftrong ftimulus applied, or of a fhong 
fpafm formed, the latter appearing in a con- 
fiderable fuppreflion of the excretions. 

CIV. 

The fymptoms which denote a great degree 
of debility, are, 

In the Animal Functions: I. The 
weaknefs of the voluntary motions ; II. The 
irregularity of the voluntary motions, de- 
pending on their debility ; III. The weaknefs 
of fenfation ; IV. The weaknefs and irregu- 
larity of the intellectual operations. 

In the Vital Function s : I. The weak- 
nefs of the pulfe ; II. The coldnefs orfhrink- 
ingof the extremities ; III. The tendency to 
a deliqidum animi in an erect poflure j IV. 
The weaknefs of refpiration. 

In the Natural Functions: I. The 
weaknefs of the flomach, as appearing in an- 
orexia, 



OF PHYSIC. 113 

orexia, naufea, and vomiting ; II. Invol- 
untary excretions depending upon a pal fy 
of the fphinfters ; III. Difficult deglutition, 
depending upon a palfy of the mufcles of the 
fauces. 

cv. 

Laflly, The fymptoms denoting the putref- 
centflate of the fluids, are, 

I. With refpecl: to the ftomach ; the loath- 
ing of animal food, naufea and vomiting, great 
thirfl, and a defire of acids. 

II. With refpecl: to the fluids ; 1. The 
blood drawn out of the veins not coagulating 
as ufual ; 2. Hemorrhagy from different 
parts, without marks of increafed impetus j 
3. Effufions under the fkin or cuticle, forming 
petechia?, maculae, and vibices ; 4. Effufions 
of a yellow ferum under the cuticle. 

III. With refpecl; to the ftate of the excre- 
tions ; fetid breath, frequent loofe and fetid 
ltools, high coloured turbid urine, fetid fweats, 
and the fetor and livid colour of blillered 
places. 

IV. The cadaverous fmell of the whole 
body. 

CVI. 

Thefe feveral fymptoms have very often, 
each of them fingly, a fhare in determining the 
prognoftic ; but more efpecially by their 

concurrence 



ii4 PRACTICE 

concurrence and combination with one anoth- 
er j particularly thofe of debility with thofe 
of putrefcency. 

CVII. 

On the fubjecl of the prognoftic, it is prop- 
er to obferve, that many phylicians have been 
of opinion there is fomething in the nature of 
fevers which generally determines them to be 
of a certain duration ; and therefore that their 
terminations, whether falutary or fatal, hap- 
pen at certain periods of the difeafe, rather 
than at others. Thefe periods are called the 
Critical Days ; carefully marked by Hip- 
pocrates and other ancient phyficians, as well 
as by many moderns of the greateft eminence 
in practice ; whilft at the fame time many oth- 
er moderns, of no inconfiderable authority, 
deny their taking place in the fevers of thefe 
northern regions which we inhabit. 

CVIII. 

I am of opinion that the do£trine of the an- 
cients, and particularly that of Hippocrates, 
on this fubjecl;, was well founded ; and that k 
is applicable to the fevers of our climate. 

CIX. 

I am of this opinion, Jirfl, Becaufe I ob- 
ferve that the animal economy, both from its 

own 



OF PHYSIC. 115 

own conftitution, and from habits which are 
eafily produced in it, is readily fubjetted to 
periodical movements. Secondly, Becaufe, in 
the difeafes of the human body, I obferve pe- 
riodical movements to take place with great 
conflancy and exa&nefs ; as in the cale of in- 
termittent fevers, and many other difeafes. 

ex. 

Thefe confederations render it probable, 
that exatt periodical movements may take 
place in continued fevers ; and I think there 
is evidence of fuch movements actually taking 
place. 

CXI. 



The critical days, or thofe on which we 
fuppofe the termination of continued fevers 
efpecially to happen, are, the thir d, fifth, fev- 
cnth, ninth, eleventh, fourteenth, feventeenth, 
and twentieth. We mark none beyond this 
Iaft: ; becaufe, though fevers are fometimes 
protracted beyond this period, it is, however, 
more rarely ; fo that there are not a fufficient 
number of obfervations to afcertain the courfe 
of them ; and further, becaufe it is probable 
that, in fevers long protracted, the movements 
become lefs exacl; and regular, and therefore 
lefs eafily obferved. 

CXII, 



n6 PRACTICE 



CXII. 

That the days now mentioned are the crit- 
ical days, teems to be proved by the particu- 
lar fafts which are found in the writings of 
Hippocrates. From thefe fads, as collecled 
from the fevcral writings of that author by 
M. de Haen y it appears, that of one hundred 
and fixty three instances of the termination of 
fevers, which happened on one or other of the 
ftrft twenty days of the difeafe, there are one 
hundred and feven, or more than two thirds 
of the whole number, which happened on one 
or other of the eight days above mentioned ; 
that none happened on the fecond or thir- 
teenth day ; and upon the eighth, tenth, 
twelfth, fifteenth, fixteenth, eighteenth, and 
nineteenth, there are but eighteen inftances of 
termination, or one ninth of the whole. 

GXIIl/ 

As the terminations which happen on the 
feven days lafh mentioned, are, upon the 
whole, few ; and, upon any one of them, few- 
er than thofe which happen on any of our 
iuppofed critical days ; fo there are therefore 
nine days which may be called noncriti- 
cal; while, on the other hand, the many ter- 
minations which happened on the feventh, 
fourteenth, and twentieth days, afford a proof 
both of critical days in general, and that thefe 

are 



OF PHYSIC. 117 

arc the chief of them. Hereafter I fhall men- 
tion an analogy that renders the power of the 
other critical days i'ufficiently probable. 

CXIV. 

It appears further, that as, of the termina- 
tions which were final and falutary, not a 
tenth part happened on the noncritical days ; 
and of the terminations which were final and 
fatal, though the greater number happened 
on the critical days, yet above a third of them 
happened on the noncritical j ft) it would ap- 
pear, that the tendency of the aiiimal economy 
is to obierve the critical days, and that it is 
by the operation of iome violent and irregular 
caufe that the courfe of things is fometimes 
turned to the noncritical. 

CXV. 

What has been faid gives fufficient ground 
for presuming, that it is the general tendency 
of the animal economy to determine the pe- 
riodical movements in fevers to be chiefly on 
the critical days. At the fame, time, we muft 
acknowledge it to be a general tendency only ; 
and that, in particular cafes, many circum- 
ftances may occur to difturb the regular courfe 
of it. Thus, though the chief and more re- 
markable exacerbations in continued fevers 
happen on the critical days, there are truly 
exacerbations happening every day ; and 

thefe, 



n8 PRACTICE 

thefe, from certain caufes, may become con- 
fiderable and critical. Further, though in- 
termittent fevers are certainly very ftrongly 
determined to obferve a tertian or quartan 
period, we know there are circumftances which 
prevent them from observing thefe periods 
exactly, and which render them either antici- 
pating or poftponing fo much, that the days 
of paroxyfms come to be quite changed ; and 
it is allowable to fuppofe, that the like may 
happen with refpecl; to the exacerbations of 
continued fevers, fo as thereby to difturb the 
regular appearance of critical days. 

A particular inftance of this occurs with re- 
fpecl; to the fixth day of fevers. In the writ- 
ings of Hippocrates, there are many inftances 
of terminations happening on the fixth day ; 
but it is not therefore reckoned among the 
critical days ; for, of the terminations happen- 
ing on that day, there is not one which proves 
finally of a falutary kind ; the greater number 
are fatal ; and all the reft are imperfect, and 
followed with a relapfe. All this mows, that 
fome violent caufe had, in thefe cafes, produc- 
ed a deviation from the ordinary courfe of 
nature ; that the terminations on the fixth day 
are nothing more than anticipations of the 
feventh, and therefore a proof of the power 
of this laft. 

CXVI. 

The doclrine of critical days has been much 
embarraffed by fome diflonant accounts of it, 

which 



OF PHYSIC. 119 

which appear in the writings imputed to Hip- 
pocrates. But this may be jultly accounted 
for from thefe writings being truly the works 
of different perfons, and from the molt genu- 
ine of them having iuffered many corruptions; 
fo that, in Ihort, every thing which is incon- 
fiftent with the facls above laid down, may 
be afcribed to one or other of thefe caufes. 

CXVII. 

This, further, has efpecially diflurbed the 
do6lrine of critical days, that Hippocrates 
himfelf attempted, perhaps too haftily, to ef- 
tabliih general rules, and to bring the do&rine 
to a general theory, drawn from Pythagorean 
opinions concerning the power of numbers. 
It is this which feems to have produced the 
idea of odd days, and of a quaternary and fep- 
tenary period, doftrines which appear fo oft- 
en in the writings of Hippocrates. Thefe, 
however, are inconfiftent with the fa&s above 
laid down ; and indeed, as Afclepiades and 
Celfus have obferved, are inconfiftent with 
one another. 

CXVIII. 

Upon the whole, therefore, it is apprehend- 
ed, that the critical days above afiigned are 
truly the critical days of Hippocrates, and 
may be confidently explained in the following 
manner. 

CXIX. 



120 PRACTICE 



CXIX. 

From the univerfality of tertian or quartan 
periods in intermittent fevers, we cannot doubt 
of there being, in the animal economy, a ten- 
dency to obferve fuch periods ; and the critical 
days above mentioned are confident with this 
tendency of the economy, as all of them mark 
either tertian or quartan periods. Thefe pe- 
riods, however, are not promifcuoufly mixed, 
but occupy conftantly their feveral portions 
in the progrefs of the difeafe ; fo that, from 
the beginning to the eleventh day, a tertian 
period takes place ; and, from the eleventh to 
the twentieth, and perhaps longer, a quartan 
period is as fleadily obferved. 

CXX. 

What determines the periods to be changed 
about tne eleventh day, we have not clearly 
perceived ; but the facl: is certain ; for there 
is no inftance of any termination on the thir- 
teenth, that is, the tertian period next follow- 
ing the eleventh ; whereas, upon the four- 
teenth, feventeenth, and twentieth, which 
mark quartan periods, there are forty three 
inftances of terminations, and fix only on all 
the intermediate days between thefe. 

This prevalence of a quartan period leave? 
no room for doubting that the twentieth, and 
not the twenty firft, is the critical day marked 

by 



OF PHYSIC. 121 

by Hippocrates, though the Iaft is mentioned 
as fuch in the common edition of the Aphor- 
ifms, taken from an erroneous manufcript, 
which Celfus alfo feems to have copied. 

CXXI. 

A confiftency with the general tendency of 
the fyftem, renders the feries of critical days 
we have mentioned, probably the true one ; 
and the only remaining difficulty in finding 
what we have delivered to be the fame with 
the genuine do6lrine of Hippocrates, is the 
frequent mention of the fourth as a critical 
day. 

It is true there are more inflances of termi- 
nations happening on this day than on fome 
of thofe days we have aflerted to be truly 
critical ; but its inconfiflency with the more 
general tendency, and fome other cohfidera- 
tions, lead us to deny its being naturally a 
critical day ; and to think, that the inflances 
of terminations, which have really occurred 
on the fourth day, are to be reckoned among 
the other irregularities that happen in this 
matter. 

CXXII. 

I have thus endeavoured to fupport the 

do6lrine of critical days, chiefly upon the 

particular facls to be found in the writings of 

Hippocrates : And although I might alfo 

F produce 



122 PRACTICE 

produce many other teflimonies of both an- 
cient and modern times ; yet it mufl be own- 
ed, that fome of thefe teflimonies may be fuf- 
pecled to have arifen rather from a veneration 
of Hippocrates, than from accurate obferva- 
tion. 

CXXIII. 

With refpect to the opinions of many mod- 
erns who deny the prevalence of critical days, 
they are to be little regarded ; for the observa- 
tion of the courfe of continued fevers is known 
to be difficult and fallacious ; and therefore 
the regularity of that courfe may have often 
efcaped inattentive and prejudiced obfervers. 

CXXIV. 

Our own obfervations amount to this, that 
fevers with moderate fymptoms, generally 
cafes of the fynocha, frequently terminate in 
nine days, or looner, and very conftantly up- 
on one or other of the critical days which fall 
within that period ; but it is very rare, in this 
climate, that cafes of either the typhus or 
fynochus terminate before the eleventh day ; 
and, when they do terminate on this day, it is 
for the mod part fatally. When they are 
protracted beyond this time, I have very con- 
ftantly found, that their terminations were up- 
on the fourteenth, Seventeenth, or twentieth 
day. 

In 



OF PHYSIC. 123 

In fuch cafes, the falutary terminations are 
feldom attended with any coniiderable evacu- 
ation. A fweating frequently appears, but is 
feldom confiderable ; and I have hardly ever 
obferved critical and decifive terminations at- 
tended with vomiting, evacuations by ftool, or 
remarkable changes in the urine. The folution 
of the difeafe is chiefly to be difcerned from 
fome return of fleep and appetite, the ceafing 
of delirium, and an abatement of the frequen- 
cy of the pulfe. By thefe fymptoms we can 
often mark a crifis of the difeafe ; but it fel- 
dom happens fuddenly and entirely ; and it is 
mofl commonly from fome favourable fymp- 
toms occurring upon one critical day, that we 
can announce a more entire folution upon the 

next following, 
o 

Upon the whole, I am perfuaded, that, if 
obfervations fhall be made with attention, and 
without prejudice, I fhall be allowed to con- 
clude with the words of the learned and faga- 
cious Gaubius, " Fallor, ni fua conflitent 
rc Hippocrati aucloritas, Galeno fides, 
"* Nature virtus et ordo." 



F 2 CHAP. 



i2 4 PRACTICE 

CHAP. VI. 
of t&e METHOD of CURE in Fevers. 

SECT. I. 

Of the CURE of CONTINUED FEVERS. 

exxv. 

As it is allowed, that, in ev- 
ery fever which has its full courfe, there is an 
effort of nature of a falutary tendency, it might 
be krppofed that the cure of fevers mould be 
left to the operations of nature, or that our art 
mould be only direfted to fupport and regu- 
late thefe operations, and that we mould form 
our indications accordingly. This plan, how- 
ever, I cannot adopt, becaufe the operations 
of nature are very precarious, and not fo well 
underftood as to enable us to regulate them 
properly. It appears to me, that t rutting to 
thefe operations has often given occafion to a 
negligent and inert practice ; and there is rea- 
fon to believe, that an attention to the opera- 
tions of nature may be often fuperfeded by 

art, 

CXXVI. 



OF PHYSIC. 125 



CXXVI. 

The plan which to me appears to be 
mod fuitable, is that which forms the indica- 
tions of cure upon the view of obviating the 
tendency to death ; while, at the fame time, 
the means of executing thefe indications are 
directed by a proper attention to the proxi- 
mate caufe of fevers. 

Upon this plan, in confequence of what has 
been laid down above on the fubject of the 
prognoftic, we form three general indications 
in the cure of continued fevers ; and the one 
or other of thefe is to be employed according 
as the circumilances of the fever (CII.) mall 
direct. 

The ftrft therefore is, To moderate the vio- 
lence of reaction. 

The fecond is, To remove the caufes or ob~ 
viate the effects of debility. And, 

The third is, To obviate or correct the ten- 
dency of thefuids to putrefaction. 

CXXVII. 

The firfl indication may be anfwered, that 
is, the violence of reaction may be moderated, 

1. By all thofe means which diminifh the 
action of the heart and arteries. 

2. By thofe means which take off the fpafm 
of the extreme veffels, which we fuppofe to 
be the chief caufe of violent reaction. 

F 3 CXXVIII. 



126 PRACTICE 

CXXVIII. 

The a£tion of the heart and arteries may 
be diminifhed, 

1. By avoiding or moderating thofe irrita- 
tions, which, in one degree or other, are al- 
moft conftantly applied to the body. 

2. By the ufe of certain fedative powers. 

3. By diminifhing the tenfion and tone of 
the arterial fyftem. 

CXXIX. 

The irritations (CXXVIII. 1.) almoft 
conftantly applied, are the impreflions made 
upon our fenfes ; the exercife of the body and 
mind ; and the taking in of aliments. The 
avoiding thefe as much as poffible, or the mod- 
erating their force, conftitute what is rightly 
called the Antiphlogistic Regimen, 
proper to be employed in almoft every con- 
tinued fever. 

cxxx. 

The conduct, of this regimen is to be direct- 
ed by the following rules and confiderations. 

1 . Impreflions on the external fenfes, as be- 
ing ftimulant to the fyftem, and a chief fup- 
port of its activity, fhould be avoided as much 
as poffible ; thofe efpecially of more conftant 
application, thofe of a ftronger kind, and thofe 
which give pain and uneafinefs. 

No 



OF PHYSIC. 187 

No impreffion is to be more carefully guard- 
ed againft than that of external heat ; while, at 
the fame time, every other means of increaf- 
ing the heat of the body is to be fhunned. 
Both thefe precautions are to be obferved as 
foon as a hot ftage is fully formed, and to be 
attended to during its continuance ; excepting 
in certain cafes, where a determination to 
fweating is neceffary, or where the flimulant 
effe&s of heat may be compenfated by circum- 
ftances which determine it to produce a relax- 
ation and revulfion. 

2. All motion of the body is to be avoided, 
efpecially that which requires the exercife of 
its own mufcles ; and that poflure of the body 
is to be chofen which employs the feweft muf- 
cles, and which keeps none of them long in a 
ftate of contraction. Speaking, as it accelerates 
refpiration, is particularly to be refrained from. 

It is to be obferved, that every motion of 
the body is the more flimulant in proportion 
as the body is weaker. , 

3. The exercife of the mind alfo is a ftim- 
ulus to the body ; fo that all impreffions which 
lead to thought, and thofe efpecially which 
may excite emotion or paffion, are to be care- 
fully fhunned. 

With refpetl to avoiding impreffions of 
all kinds, an exception is to be made in the 
cafe of a delirium coming on, when the pre- 
fenting of accuftomed objects may have the 
effect of interrupting and diverting the irreg- 
ular train of ideas then arifing in the mind. 

F 4 4. The 



128 PRACTICE 

4. The prefence of recent aliment in the 
ftomach proves always a ftimulus to the fyftem, 
and ought therefore to be as moderate as pof- 
fible. A total abflinence for fome time may 
be of fervice ; but as this cannot be long con- 
tinued with fafety, we mud avoid the ftimulus 
of aliment, by choofing that kind which gives 
the leaft. We fuppofe that alimentary mat- 
ters are more ftimulant, according as they are 
more alkalefcent ; and this leads to avoid all 
animal, and to ufe vegetable food only. 

As our drinks alfo may prove ftimulant, fo 
all aromatic and fpirituous liquors are to be 
avoided ; and, in anfwering the prefent indi- 
cation, all fermented liquors, excepting thofe 
of the loweft quality, are to be abftainedfrom. 

CXXXI. 

Befides thefe ftimulant powers more con- 
ftantly applied, there are others which, al- 
though occafional only, yet, as commonly 
accompanying fevers, mufl be attended to and 
removed. 

One is, the fenfe of thirft, which, as a pow- 
erful ftimulus, ought always, in one \vay or 
other, to be removed. 

Another ftimulus frequently arifes from 
crudities, or corrupted humours, in the ftom- 
ach ; and it is to be removed by vomiting, by 
dilution, or by the ufe of acids. 

A third ftimulus often arifes from the pre- 
ternatural retention of faeces in the intef- 
tines ; and ought to be removed by frequent 
laxative glyfters. A 



OF PHYSIC. 129 

A'fourth ftimulus to be conftantly fufpcft- 
ed in fevers, is a general acrimony of the flu- 
ids, as produced by the increafe of motion 
and heat, joined with an interruption of the 
excretions. This acrimony is to be obviated 
or removed by the taking in of large quantities 
of mild antifeptic liquors. 

CXXXII. 

The avoiding of irritation in all thefe par- 
ticulars, (CXXX. and CXXXI.) conftitutes 
the antiphlogiftic regimen abfolutely necefia- 
ry for moderating the violence of reaftion ; 
and, if I miftake not, is proper in almoft 
every circumftance of continued fevers ; be- 
caufe the propriety and fafety of employing 
flimulant., is often uncertain -, and becaufe 
feveral of thofe above mentioned, befide their 
flimulant powers, have other qualities by 
which they may be hurtful. 

It appears to me, that the fuppofed utility 
of ftimulants, in certain cafes of fever, has oft- 
en arifen from a miftake in having afcribed to 
their flimulant what really depended upon 
their antifpafmodic power, 

CXXXIII. 

A fecond head of the means (CXXVIII; 
2.) for moderating the violence of reaction ., 
comprehends certain fedative powers, which 

may 

K 5 



130 PRACTICE 

may be employed to diminifh the activity of 
the whole body, and particularly that of the 
Sanguiferous fyftem. 

The Jirji of thefe to be mentioned is the 
application of cold. 

Heat is the chief fupport of the activity of 
the animal fyftem ; which is therefore provid- 
ed in itfelf with a power of generating heat. 
But, at the fame time, we obferve, that this 
would go to excefs, were it not conftantly 
moderated by a cooler temperature in the fur- 
rounding atmoiphere. When, therefore, 
that power of the fyftem generating heat is in- 
creased, as is commonly the cafe in fevers, it 
is necelfary not only to avoid all means of in- 
creafmg it further, but it feems proper alfo to 
apply air of a cooler temperature ; or at leaft 
to apply it more entirely and freely, than in a 
ftate of health. 

Some late experiments in the fmall pox and 
in continued fevers, fliow that the free admif- 
i'ion of cool air to the body is a powerful rem- 
edy in moderating the violence of reaction ; 
but what is the mode of its operation, to what 
circumftances of fever it is peculiarly adapt- 
ed, or what limitations it requires, I fhall not 
venture to determine, till more particularly 
inftructed by further experience. 

CXXXIV. 

A fecond fedative power which may be em- 
ployed in fevers., is that of certain medicines, 

known, 



OF PHYSIC. 131 

Known, in the writings on the Materia Medi- 
ca, under the title of Refrigerants. 

The chief of thefe are acids of all kinds, 
when fufficiently diluted ; and they are, in 
feveral refpe&s, remedies adapted to continu- 
ed fevers. Thofe efpecially in ufe are, the 
Vitriolic and Vegetable ; and, on many ac- 
counts, we prefer the latter.- 

cxxxv. 

Another fet of refrigerants are, the Neutral 
Salts, formed of the vitriolic, nitrous or vege- 
table acids; with alkalines, either fixed or 
volatile. All thefe neutrals, while they are 
diffolving in water, generate cold • but as 
that cold ceafes foon after the folution is 
fmifhed, and as the falts are generally exhib- 
ited in a diffolved flate, their refrigerant pow- 
er in the animal body does not at all depend 
upon their power of generating cold with wa- 
ter. The neutral chiefly employed as a refrig- 
erant, is Nitre ; but all the others, com- 
pounded as above mentioned, partake more or 
lefs of the fame quality, 

CXXXVI. 

Eelides thefe neutrals, fome metallic falts 
alfo have been employed as refrigerants in 
fevers ; and particularly the Sugar of Lead. 
Bat the refrigerant powers of this are not well 
afcertained ; and its deleterious qualities are 
too well known to admit of its being freely 
ftfedi 

F 6 CXXXVII. 



132 PRACTICE 

CXXXVII. 

Under the t hi rd general head (CXXVIII. 
3.) of the means to be employed for moderat- 
ing the violence of reaction, are comprehend- 
ed the feveral means of diminishing the ten- 
lion, tone, and activity, of the fanguiferous 
fyftem. As the activity of this fyllem de- 
pends, in a great meafure, upon the tone, and 
this again upon the tenfion of the veffels, giv- 
en to them by the quantity of fluids they 
contain, it is evident, that the diminution 
of the quantity of thefe, muft diminifh the 
activity of the fanguiferous fyftem. 

CXXXVIII. 

The quantity of fluids contained in the 
fanguiferous fyftem, may be diminifhed mod 
conveniently by the evacuations of blood let- 
ting and purging. 

CXXXIX. 

Nothing is more evident, than that blood 
letting is one of the moft powerful means of 
diminifhing the activity of the whole body, 
eipecially of the fanguiferous fyftem ; and it 
muft therefore be the moft effectual means of 
moderating the violence of reaction in fevers. 
Taking this as a fa6l, I omit inquiring into its 
mode of operation, and (hall only confider in 

what 



O F P H Y S I C. 133 

what circumftances of fevers it may be moft 
properly employed. 

CXL. 

When the violence of reaction, and its con- 
ftant attendant, a phlogiftic diathefis, are fuf- 
ficiently manifeft ; when thefe conflitute the 
principal part of the difeafe, and may be ex- 
pected to continue throughout the whole of it, 
as in the cafes oifynochaj then blood letting 
is the principal remedy, and may be employed 
as far as the fymptoms of the difeafe may feem 
to require, and the conflitution of the patient 
will bear. It is, however, to be attended to, 
that a greater evacuation than is neceffary, 
may occafion a flower recovery, may render 
the perfon more liable to a relapfe, or may 
bring on other difeafes. 

CXLI. 

In the cafe of fynocha > therefore, there is 
little doubt about the propriety of blood let- 
ting ; but there are other fpecies of fever, as 
the Jynochus, in which a violent reaction and 
phlogiftic diathefis appear, and prevail dur- 
ing fome part of the courfe of the difeafe ; 
while, at the fame time, thefe circumftances 
do not conftitute the principal part of the dif- 
eafe, nor are to be expected to continue dur- 
ing the whole courfe of it ; and it is well 
known, that, in many cafes, the ftate of violent 

reaction 



134 PRACTICE 

reaction is to be fucceeded, fooner or later, by 
a ftate of debility, from the excefs of which 
the danger of the difeafe is chiefly to arife. It 
is, therefore, neceflary, that, in many cafes, 
blood letting mould be avoided ; and even al- 
though during the inflammatory ftate of the 
difeafe, it may be proper, it will be neceflary 
to take care that the evacuation be not fo large 
as to increafe the ftate of debility which is to 
follow. 



CXLII. 

From all this it muft appear, that the em- 
ploying blood letting, in certain fevers, re- 
quires much difcernment and Ikill, and is to 
be governed by the confederation of the fol- 
lowing circumftances : 

1. The nature of the prevailing epidemic. 

2. The nature of the remote caufe. 

3. The feafon and climate in which the 
difeafe occurs. 

4. The degree of phlogiftic diathefis pref- 
ent. 

5. The period of the difeafe. 

6. The age, vigour, and plethoric ftate of 
the patient. 

7. The patient's former difeafes and habits 
of blood letting. 

8. The appearance of the blood drawn out. 

9. The effefts of the blood letting that 
may have been already pra&ifed. 

cxLirr. 



OF PHYSIC. 135 



CXLIII. 

When, after the confideration of thefe cir- 
cumftances, blood letting is determined to be 
neceffary, it mould be obferved, that it is 
more effectual, according as the blood is more 
fuddenly drawn off, and as the body is at the 
fame time more free from all irritation, and 
confequently when in a pofture in which the 
feweft mufcles are in action. 

CXLIV. 

Another evacuation whereby the quantity 
of fluids contained in the body can be confid- 
erably diminifhed, is that of Purging. 

CXLV. 

If we confider the quantity of fluids con- 
ftantly prefent in the cavity of the inteftines, 
and the quantity which may be drawn from the 
innumerable excretories that open into this 
cavity, it will be obvious, that a very great 
evacuation can be made by purging ; and, if 
this be done by a ftimulus applied to the intef- 
tines, without being at the fame time commu- 
nicated to the reft of the body, it may, by emp- 
tying both the cavity of the inteftines, and the 
arteries which furnifh the excretions poured 
into it, induce a confiderable relaxation in 
the whole fyftem j and therefore, purging 

feems 



136 PRACTICE 

feems to be a remedy fuited to moderate the 
violence of reaction in fevers. 

CXLVI. 

But it is to be obferved, that, as the fluid 
drawn from the excretories opening into the 
interlines, is not all drawn immediately from 
the arteries, as a part of it is drawn from the 
mucous follicles only ; and as what is even 
more immediately drawn from the arteries, is 
drawn off flowly ; fo the evacuation will not, 
in proportion to its quantity, occafion fuch a 
fudden depletion of the red veflels as blood 
letting does ; and therefore cannot operate fo 
powerfully in taking off the phlogiflic diathe- 
fis of the fyftem. 

CXLVII. 

At the fame time, as this evacuation may 
induce a confiderable degree of debility ; fo, 
in thofe cafes in which a dangerous ftate of 
debility is likely to occur, purging is to be 
employed with a great deal of caution j and 
more efpecially as the due meafure of the 
evacuation is more difficult to be applied than 
in the cafe of blood letting. 

CXLVIII. 

As we fhall prefently have occafion to ob- 
ferve, that it is of great importance, in the 

cure 



OF PHYSIC. 137 

cure of fevers, to reftore the determination of 
the blood to the veflels on the furface of the 
body ; fo purging, as in fome meafure taking 
off that determination, feems to be an evacua- 
tion not well adapted to the cure of fevers. 

CXLIX. 

If, notwithftanding thefe doubts, (CX LVI. 
CXLVII.andCXLVIII.jitmallbeafferted, 
that purging, even from the exhibition of 
purgatives, has often been ufeful in fevers ; I 
would beg leave to maintain, that this has not 
happened from alarge evacuation ; and, there- 
fore, not by moderating the violence of reac- 
tion, excepting in the cafe of a more purely 
inflammatory fever, or of exanthemata of an 
inflammatory nature. In other cafes of fever, 
I have feen a IargOfcracuation by purging, of 
mifchievous conference j and if, upon occa- 
fion, a more moderate evacuation has appear- 
ed to be ufeful, it is apprehended to have been 
only by taking off the irritation of retained 
faeces, or by evacuating corrupted humours 
which happened to be prefent in the intef- 
tines ; for both of which purpofes, frequent 
laxatives may be properly employed. 

CL. 

Another fet of means (CXXVII. 2.) for 
moderating the violence of reaction in fevers, 
are thofe fuited to take off the fpafm of the 

extreme 



138 PRACTICE 

extreme veffels, which we believe to be the ir- 
ritation that chiefly fupports the reaction. 

Though I have put here this indication of 
taking off the fpafm of the extreme veffels, as 
fubordinate to the general indication of mod- 
erating the violence of reaction ; it is howev- 
er to be obferved here, that as fever univer- 
fally confifts in an increafed a&ion of the 
heart, either in frequency or in force, which 
in either cafe is fupported by a fpafm of the 
extreme veffels, fo the indication for remov- 
ing this is a very general one, and applicable 
in almoft every circumftance of fever, or at 
leaft with a few exceptions, to be taken notice 
of hereafter. 

CLL 

For taking off the fp$fi» of the extreme 
veffels, the means to be employed are either 
internal or external. 

CLII. 

The internal means (CLI.) are, 

1. Thofe which determine the force of the 
circulation to the extreme veffels on the furface 
of the body, and, by reftoring the tone and 
activity of thefe veffeh, may overcome the 
fpafm on their extremities. 

2. Thofe medicines which have the power 
of taking off fpafm in any part of the fyflem, 
and which are known under the title of An- 
tispasmodics. CLIII, 



OF PHYSIC. 139 



CLIII. 

Thofe remedies which are fit to determine 
to the furface of the body, are, 

1. Diluents. 

2. Neutral Salts. 

3. sudorifics. 

4. Emetics. 

CUV. 

Water enters, in a large proportion, into 
the compofition of all the animal fluids, and a 
large quantity of it is always diffufed through 
the whole of the common mafs. Indeed, in 
a found flate, the fluidity of the whole mafs 
depends upon the quantity of water prefent 
in it. Water, therefore, is the proper diluent 
of our mafs of blood ; and other fluids are dil-*^ 
uent only in proportion to the quantity or'* 
water they contain. 

CLV. 

Water may be faid to be the vehicle of the 
feveral matters which ought to be excerned ; 
and in a healthy ftate the fulnefs of the ex- 
treme veflels, and the quantity of excretions, 
are nearly in proportion to the quantity of 
water prefent in the body. In fever, how- 
ever, although the excretions are in fome 
meafure interrupted, they continue in fuch 

quantity 



i40 PRACTICE 

quantity as to exhale the more fluid parts of 
the blood ; and while a portion of them is at 
the fame time neceffarily retained in the larger 
veffels, the fmaller and the extreme veffels, 
both from the deficiency of fluid, and their 
own contracted ftate, are lefs filled, and there- 
fore allowed to remain in that condition. 

CLVI. 

To remedy this contracted flate, nothing is 
more neceflary than a large fupply of water or 
watery fluids, taken in by drinking or other- 
wife ; for as any fuperfluous quantity of water 
is forced off by the feveral excretories, fuch a 
force applied, may be a means of dilating the 
extreme veffels, and of overcoming the fpafm 
affecting their extremities. 

k CLVII. 

Accordingly the throwing in of a large 
quantity of watery fluids has been, at all times, 
a remedy much employed in fevers ; and in 
no inftance more remarkably, than bv the 
Spanifh and Italian phyficians, in the ufe of 
what they call the JMata aquea. 

CLVIII. 

This practice confifts in taking away every 
other kind of aliment and drink, and in giv- 
ing in divided portions every day, for feveral 

days 



OF PHYSIC. 141 

days together, fix or eight pounds of plain 
water, generally cold, but fometimes warm. 
All this, however, is to be done only after the 
difeafe has continued for fome time, and, at 
leaft, for a week. 

CLIX. 

A fecond means (CLIII. 2.) of determin- 
ing to the furface of the body, is by the ufe of 
neutral falts. Thefe, in a certain dofe taken 
into the ftomach, produce, foon after, a fenfe 
of heat upon the furface of the body ; and, if 
the body be covered clofe and kept warm, a 
fweat is readily brought out. The fame med- 
icines, taken during the cold ftage of a fever, 
very often put an end to the cold ftage, and 
bring on the hot ; and they are alfo remarka- 
ble for flopping the vomiting which fo fre- 
quently attends the cold ftage of fevers. All 
this fhows, that neutral falts have a power of 
determining the blood to the furface of the 
body, and may therefore be of ufe in taking 
off the fpafm which in fevers fubfifts there. 

CLX. 

The neutral mod commonly employed in 
fevers, is that formed of an alkali with the 
native acid of vegetables ; but all the other 
neutrals have more or lefs of the fame virtue; 
and perhaps fome of them, particularly the am- 
moniacal falts, poftefs it in a ftronffer degree. 

CLXI. 



14a PRACTICE 



CLXI. 

As cold water taken into the ftomach, oft- 
en fhows the fame diaphoretic effects with the 
neutral falts, it is probable that the effecl; of 
the latter depends upon their refrigerant pow- 
ersmentionedabove,(CXXXIV.) What is the 
efFeft of the neutral ialts, given when they are 
forming and in a ftate of effervefcence ? It is 
probable that this circumftance may increafe 
the refrigerant power of thefe falts, and may 
introduce into the body a quantity of fixed 
air; but for thefe purpofes it would feem prop- 
er to contrive that the whole of the effervef- 
cence Ihould take place in the ltomach. 

CLXII. 

A third means (CLIII. 3.) of determining 
to the furface of the body, and taking off the 
fpafm fubfifting there, is by the ufe of fudo- 
rific medicines, and of fweating. 

CLXIIL 

The propriety of this remedy has been 
much difputed ; and fpecious arguments may 
be adduced both for and againft the practice. 

In favour of the practice, it may be laid ; 

1. That, in healthy perfons, in every cafe 
of increafed aftion of the heart and arteries, a 
fweating takes place, and is feemingly the 

means 



OF PHYSIC. 143 

means of preventing the bad effects of fuch 
increafed action. 

2. That, in fevers, their mofl ufual folu- 
tion and termination is by fpontaneous fwcat- 
ing. 

3. That, even when excited by art, it has 
been found manifeftly ufeful, at certain peri- 
ods, and in certain fpecies of fever. 

CLXIV. 

Upon the other hand, it may be urged a- 
gainfl the practice of fweating ; 

1. That as in fevers a fpontaneous fweating 
does not immediately come on, fo there muft 
be in thefe fome circumftances different from 
thofe in the ftate of health, and which may 
therefore render it doubtful whether the fweat- 
ing can be fafely excited by art. 

2. That, in many cafes, the practice has 
been attended with bad confequences. The 
means commonly employed have a tendency 
to produce an inflammatory diathefis ; which, 
if not taken off by the fweat following their 
ufe, muft be increafed with much danger. 
Thus fweating employed to prevent the ac- 
ceffions of intermitting fevers, has often chang- 
ed them into a continued form, which is al- 
ways dangerous. 

3. The utility of the practice is further 
doubtful, becaufe fweating, when it happens, 
does not always give a final determination ; 
^s mull be manifeft in the cafe of intermit- 
tent^ 



144 PRACTICE 

tents, as well as in many continued fevers, 
which are fometimes in the beginning attend- 
ed with fweatings that do not prove final ; and, 
on the contrary, whether fpontaneous or ex- 
cited by art, feem often to aggravate the dif- 
eafe. 

CLXV. 

From thefe confiderations, it is extremely 
doubtful if the practice of fweating can be ad- 
mitted very generally ; but, at the fame time, 
it is alfo doubtful, if the failure of the practice, 
or the mifchiefs faid to have arifen from it, have 
not been owing to the improper conduct of 
the practitioner. 

With refpect to this laft, it is almoft agreed 
among phyficians, 

1. That fweating has been generally hurt- 
ful when excited by flimulant, heating, and 
inflammatory medicines. 

2. That it has been hurtful when excited 
by much external heat, and continued with a 
great increafe of the heat of the body. 

3. That it is always hurtful when it does 
not foon relieve, but rather increafes, the fre- 
quency and hardnefs of the pulfe, the anxiety 
and difficulty of breathing, the headach, and 
delirium. $ 

4. That it is always hurtful if it be urged 
when the fweat is not fluid, and when it is 
partial, and on the fuperior parts of the body 
only. 

CLXVI. 



OF PHYSIC. *45 

CLXVI. 

In thefe cafes, it is probable, that either an 
inflammatory diathefis is produced, which m- 
creafes the fpafm on the extreme velTels ; or 
that, from other caufes, the fpafm is too much 
fixed to yield eafily to the increafed attion of 
the heart and arteries ; and, upon either fup- 
pofition, it muft be obvious, that urging the 
fweat, as ready to produce a hurtful determi- 
nation to fome of the internal parts, may be 
attended with very great danger. 

CLXVII. 

Though the doubts ftarted (CLXIV.) are 
to be attended to ; and although the practices 
(CLXV.) having been found hurtful, are 
therefore to be rejected ; it ftill remains true, 

1. That fweating has certainly been often 
ufeful in preventing the acceffion of fevers, 
when the times of this have been certainly 
forefeen, and a proper conduct employed. 

2. That, even after fevers have in fome 
meafure come on, fweating, when properly 
employed, either at the very beginning of the 
difeafe, or during its approach and gradual 
formation, has often prevented their further 
prog re fs. 

3. That, even after pyrexiae have continu- 
ed for fome time, fweating has been fucceff- 
fully employed in curing them, as particular- 
ly in the cafe of rheumatifm. 

G 4. Tliat 



146 PRACTICE 

4. That certain fevers, produced by a very 
powerful fedative contagion, have been gener- 
ally treated, fo far as we yet know, mofl fuc- 

celsfully by fweating. 

CLXvni. 

Thefe inftances (CLXVII.) are in favour 
of fweating, but give no general rule ; and it 
mult be left to further experience to deter- 
mine how far any general rule can be eftab- 
Jiihed in this matter. In the mean time, if 
the practice of fweating is to be attempted, we 
can venture to lay down the following rules 
for the conduct of it. 

1. That it mould be excited without the 
ufe oi ft imulant inflammatory medicines. 

2. That it mould be excited with as little 
external heat, and with as little increafe of the 
heat of the bod)-, as poffible. 

3. That, when excited, it mould be contin- 
ued for a due length of time, not lefs than 
twelve hours, and fometimes for twenty four 
or forty eight hours ; always, however, pro- 
viding that it proceeds without the circum- 
liances mentioned (CLXV. 3. 4.) 

4. That for fome part of the time, and as 
long as the perfon can cafdy bear, it mould 
be carried on without admitting of deep. 

5. That it mould be rendered univerfal 
over the whole body ; and, therefore, particu- 
larly, that care be taken to bring the fweating 
to the lower extremities. 

6. That 



OF PHYSIC. 147 

6. That the practice fhould be rendered 
fafer by moderate purging, excited at the fame 
time. 

7. That it mould not be fuddenly checked 
by cold any how applied to the body. 

CLXIX. 

When attention is to be given to thefe 
rules, the fweating may be excited, 1. By 
warm bathing, or a fomentation of the lower 
extremities. 2. By frequent draughts of 
tepid liquors, chiefly water, rendered more 
grateful by the addition of a light aromatic, 
or more powerful by that of a fmall quantity 
of wine. 3. By giving fome dofes of neutral 
falts. 4. Moft effectually, and perhaps mod 
fafely, by a large dofe of an opiate, joined with 
a portion of neutral falts, and of an emetic. 

In what cafes may cold water, thrown into 
the ftomach in large quantities, be employed 
to excite fweating? See Celsus, Lib. III. 
chap. vii. — ix. 

CLXX. 

The fourth means (CLIII. 1.) of deter-, 
mining to thefurfaceof the body, and thereby 
taking off the fpafm affecting the extreme vef- 
fels, is by the ufe of emetics'. 

G 2 CLXXI. 



148 PRACTICE 



CLXXI. 

Emetics, and particularly antimonial emet- 
ics, have been employed in the cure of fevers 
ever fince the introduction of chemical med- 
icines ; but, for a long time, they were em- 
ployed by chemifts and chemical practitioners 
only ; and although of late the ufe of them 
has become very general, their efficacy is flill 
difputed, and their manner of operating is not 
commonly explained. 

CLXXII. 

Vomiting is, in many refpe£ts, ufeful in fe- 
vers ; as it evacuates the contents of the ftom- 
ach ; as it emulges the biliary and pancreatic 
du6ls ; as it evacuates the contents of the du- 
odenum, and perhaps alfo of a larger portion 
of the inteftines ; as it agitates the whole of 
the abdominal vifcera, expedes the circulation 
in them, and promotes their feveral fecretions ; 
and, laflly, as agitating alfo the vifcera of the 
thorax, it has like effects there. All thefe 
feveral effects are, in many cafes and circum- 
flances of fever, procured with advantage ; but 
do not properly fall under our view here, where 
we are to confider only the effe6l of vomiting 
in determining to the furface of the body. . 

CLXXIII. 



O F P H Y S I C. 149 



CLXXIII. 

This effect: we do not impute to the exercife 
of vomiting in agitating the whole frame ; but 
to the particular operation of emetics upon the 
mufcular fibres of the ftomach, whereby they 
excite the action of the extreme arteries on the 
furface of the body, fo as thereby effectually 
to determine the blood into thefe veffels, re- 
move the atony, and take off the fpafm affect- 
ing them. 

CLXXIV. 

That fuch is the power of emetics, will ap- 
pear from the feveral confiderations mention- 
ed above (XL IV.) ; and, therefore, that they 
are remedies well fuited to the cure of fevers. 

CLXXV. 

Emetics, for that purpofe, are adminiftered 
in two different ways ; that is, either in fuch 
dofes as may excite full and repeated vomit- 
ings ; or in fuch dofes as may excite ficknefs 
and naufea only, with little or no vomiting at 

CLXXVI. 

Full vomiting is beft fuited to the feveral 

purpofes mentioned CLXXII. ; and is alfo 

G 3 well 



*5° PRACTICE 

well fuited to determine to the furface of the 
body, f'o as thereby to obviate the atony and 
fpalm which lay the foundation of fever. 
Thus vomiting, excited a little before the ex- 
pected acceffion of the paroxyfm of an inter- 
mittent, has been found to prevent the parox- 
yfm altogether. And it has been obferved 
alfo, that, when contagion has been applied to 
a perfon, and firft difcovers its operation, a 
vomit given will prevent the fever, which was 
otherwife to have been expected. See Lind 
$n Fevers and Infection. 

CLXXVII. 

Thefe are advantages to be obtained by ex- 
citing vomiting at the firft approach of fevers, 
or of the paroxyfms of fevers ; and after fevers 
are formed, vomiting may alfo be employed, 
to take off, perhaps entirely, the atony and 
fpafm, or at leaft to moderate thefe, fo that the 
fever may proceed more gently and fafely. 

CLXXVIII. 

It is feldom, however, that vomiting is found 
to produce a final folution of fevers ; and, af- 
ter they are once formed, it is commonly nec- 
effary to repeat the vomiting feveral times ; 
but this is attended with inconvenience, and 
fometimes with difadvantage. The operation 
of full vomiting commonly foon ceafes, and 
the exercife of vomiting is often a debilitating 

power j 



OF PHYSIC. 151 

power ; and therefore, when the vomiting does 
not remove the atony and fpafm very entirely, 
it may give occafion to their recurring with 
greater force. 

CLXXIX. 

For thefe reafons, after fevers are fully 
formed, phyhcians have thought proper to 
employ emetics in naufeating dofes only. 
Thefe are capable of exciting the aclion of 
the extreme vefTels, and their operation is more 
permanent. At the, fame time, they often 
(how their power by exciting fome degree of 
fweat ; and their operation is rendered more 
fafe, by their commonly producing fome evac- 
uation by ftool. 

CLXXX. 

Such are the advantages to be procured by 
naufeating dofes of emetics ; and it only re- 
mains to mention, what are the medicines moft 
fit to be employed in that manner, what are the 
moft proper times for exhibiting, and what is 
the beft manner of adminiftering them. 

CLXXXI. 

The emetics at prefent chiefly in ufe, are 
Ipecacuanha and Antimony. 

The former may be employed for every 
purpofe of emetics, particularly thofe men- 
tioned CLXXII. It may likewife be em- 
G 4 Ployed* 



15 2 PRACTICE 

ployed, either in larger or fmaller dofes, for 
determining to the furface of the body ; but, 
even in very fmall dofes, it fo readily excites 
vomiting, as to be with difficulty employed 
for the purpofe of naufeating only ; and, how- 
ever employed, there is reafon to believe, that 
its effects are lefs permanent, and lefs power- 
fully communicated from the ftomach to the 
reft of the fyftem, than thofe of Antimony. 

CLXXXII. 

This, therefore, is generally preferred ; and 
its preparations, feemingly various, may all 
be referred to two heads j the one compre- 
hending thofe in which the reguline part is in 
a condition to be acted upon by acids j and 
therefore, on meeting with acids in the ftom- 
ach, becomes active ; and the other compre- 
hending thofe preparations in which the regu- 
line part is already joined with an acid, ren- 
dering it active. 

CLXXXIII. 

Of each kind there are great numbers, but 
not differing effentially from one another. 
It will be enough for us to compare the Calx 
Antimonii Nitrata of the Edinburgh Difpen- 
fatory with the Emetic Tartar of the lame. 
The former, as I judge, is nearly the fame with 
what is called James's Powder. Which of 
thefe is beft fuited to the cure of fevers, as 

above 



OF PHYSIC. 153 

above explained, feams doubtful; but it. 
pears to me, that, although the former may 
have fome advantages from its flower opera- 
tion, and may thereby feem to be more cer- 
tainly fudorific and purgative, yet the uncer- 
tainty of its dofe renders it inconvenient, has 
often given occafion to the timid to be dif- 
appointed, and to the bold to do mifchief. 
On the other hand, the dole of the Emetic 
Tartar can be exa&ly afcertained ; and I think 
it may be exhibited in fuch a manner as to 
produce all the advantages of the other. 

CLXXXIV. 



Whichfoever of thefe preparations be em- 
ployed, I judge the moft proper time for ex- 
hibiting them, to be the time of acceflions ; or 
a little before, when that can be certainly 
known. In continued fevers, the exacerba- 
tions are not always very obfervable ; but 
is reafon to think, that one commonly hap- 
pens ?.bout noon, or foon after it, and anoth- 
er in the evening ; and that thefe, therefore, 
are the mofl proper times for exhibiting 
emetics. 

CLXXXV. 

With refpecl to the manner of aclminiftra- 
tion, that of the Calx Nitrata h ;' s the 

■ of what is judged a proper dofe 13 

G r, * 



154 PRACTICE 

at once, and no more can properly be given 
till the time of the next acceffion. 

The adminiftration of the Emetic Tartar is 
different. It is to be given in fmall doles, not 
fufficient to excite vomiting ; and thefe doles, 
after fhort intervals, are to be repeated for 
leveral times, till ficknefs, naufea, and fome, 
but not much, vomiting, come on. The dif- 
ference of this adminiilration rauft depend 
upon the dole, and the length of the intervals 
at which it is given. If it be intended that 
the medicine mould certainly operate by 
flool, the ciofes are made fmall, and the inter- 
vals long. On the contrary, when vomiting 
is proper, or when much purging ought to be 
avoided, and therefore fome vomiting mull be 
admitted, the dofes are made larger and the 
intervals Charter. 

CLXXXVI. 

With refpecl: to both kinds of preparations, 
the repetition is to be made at the times of ac- 
ceflion, but not very often ; for if the firft ex- 
hibitions, duly managed, have little effeft, it is 
felclom that the after exhibitions have much ; 
and it fometimes happens that the repeated 
vomitings, and efpecially repeated purgings, 
do harm by weakening the patient. 

CLXXXVII. 

The other fet of internal medicines, (CLII. 
?..) which I fuppofe may be uieful in taking 

off 



OF PHYSIC. 155 

cff the fpafm of the extreme veJCTels, are th< 
named Antifpafmodic. How many of thefe 
may be properly employed, I am uncertain -. 
and their mode of operation is involved in 
great obfcurity. It is certain, however, that 
opium, camphor,. mu(k y and perhaps fome 
others, have been employed in fevers with ad- 
vantage ; but the circumftances in which th. 
are efpecially proper and fafe,. I find difficult 
to afcertain ; and therefore cannot venture 
here to lay down any general doftrinc con- 
cerning them. 

CLXXXVIII. 

The external means (CLI.) fuited to take 
off the fpafm of the extreme veffels^ are Blis- 
tering and Warm Bathing. 

CLXXXIX. 

What are the efFects of Bliflering,fo frequent- 
ly employed in- fevers, is not yet agreed upon 
among phyficians ; and many different opin- 
ions have been maintained on this fubjec\ 
drawn not only from reafonirtg, but alio from 
prefumed experience. I muft not, however, 
enter into controverfy ; but lhall deliver my 
own opinion in a few words. 

cxc. 

I am perfuaded, that the fmall quantity of 

cantharides abforbed from a bliftering plafter, 

G 6 is 



156 PRACTICE 

is not fufhcient to change the confidence of 
the mafs of blood ; and therefore that fuch a 
quantity can neither do good, by refolving 
phlogiftic lentor, if it exifts ; nor do harm, 
by increafing the diffolution of the blood arif- 
ing from a putrid tendency in it. I there- 
fore neglecl entirely the effects of cantharides 
upon the fluids. 

- CXCI. 

The inflammation produced by the ap- 
plication of cantharides to the fkin, affords 
a certain proof of their flimulant power ; 
but, in many perfons, the effect of that ftim- 
ulua is not considerable ; in many, it is 
not communicated to the whole fyftem ; 
and, even when the effect: does take place in 
the whole fyftem, it feems to be taken off, 

y entirely, by the effufion and evacuation 
of ferum from the bliftered part. I conclude, 
therefore, that neither much good is to be 
expected, nor much harm to be apprehended, 
from the flimulant power of bliftering ; and 
the certainty of this conclufion is eflablifhed, 
by the great benefit arifing from the proper 
practice of biiftering in inflammatory di 

CXCII. 

Much has been imputed to the evacuation 
occa by bliftering ; but it is never fo 

con: ■ as to affect; the whole fyftem ; 

and therefore can neither, by fudden deple- 
tion, 



OF PHYSIC. 157 

tion, relax the fanguiferous veffels, nor, by 
any revulfion, affe£t the general diftribution 
of the fluids. 

CXCIII. 

The evacuation, however, is fo confider- 
able as to affedt the neighbouring veffels ; 
and the manifeft utility of bliflering near the 
part affe&ed, in inflammatory difeafes, leads 
me to believe, that bliftering, by deriving to 
the fkin, and producing an effufion there, 
relaxes the fpafm of the deeper feated veffels. 
I apprehend it to be in this manner that the 
tumour of a joint, from an effufion into the 
cellular texture under the fkin, takes off the 
rheumatic pain affecting that joint. 

CXCIV. 

Analogous to this, it may be held, that the 
good effects of bliftering in continued fevers, 
arife from its relaxing the fpafm of the ex- 
treme veffels, by a communication of the 
Wittered part with the reft of the fkin ; and 
this is illuftrated by the effe6t of bliftering in 
colic and dyfentery. 

exev. 

It appears to me, that bliftering may be 
employed at any period of continued fevers ; 
but that it will be of moft advantage in the 

advanced 



158 PRACTICE 

advanced flate of fuch fevers, when, the reac- 
tion being weaker, all ambiguity from the 
ftimulant power of bliftering is removed, and 
when it may befh concur with other circum- 
ilances tending to a final folution of the fpafm. 

CXCVI. 

From the view of this matter given in 
(CXCIII.andCXCIV.) it will appear, that 
the part of the body to which bli Iters ought 
to be applied, is indifferent, excepting upon 
the fufpicion of topical aff'e&ion, when the 
bliftering ought to be made as near as poffible 
to the part affecled. 

CXCVIL 

Whether Sinapisms, and other Rube- 
facients a, aft in a manner analogous to 
what we have fuppofed of bliftering, may be 
doubtful ; but their effects in rheumatifm,. 
and other inflammatory difeafes> render it 
probable. 

cxcvui. 

The other external means of taking off the 
fpafm of the extreme veffels, is Warm Bath- 
ing. This was frequently, and in various 
circumftances, employed by the ancients,- but 
till very lately has been neglected by modern 
phyficians. As the heat of the bath Simu- 
late* 



OF PHYSIC. 159 

lates the extreme veffels, and, with the con- 
currence of moifture, alfo relaxes them, it 
feems to be a fafe flimulus, and well fuited 
to take off the fpafm affecting them. 

cxcix. 

It may be applied to the whole body by 
immerfion ; but this is, in many refpe&s, 
inconvenient ; and whether fome of the in- 
conveniences of immerfion might not be 
avoided by a vapour bath, I have not learned 
from experience. I know, however, from 
much experience, that mod of the purpofes 
of warm bathing can be obtained by a foment- 
ation of the legs and feet, if properly admin- 
iftered, and continued for a due length of 
time, which ought not to be lefs than an hour, 

cc. 

The "marks of the good effecls of fuch a 
fomentation, are, the patient's bearing it eafily, 
its relieving delirium, and inducing fleep. 

CCI. 

Having now confidered the feveral means 
of fatisfying the fir ft general indication in the 
cure of fevers, I proceed to the fecond, 
(CXXVI.), which is, To remove the caufe, or 
obviate the ejfeEts, of debility. 

ecu. 



160 PRACTICE 

CCII. 

Mod of the fedative powers inducing de- 
bility, ceafe to act foon after they have been 
firft applied; and, therefore, the removing 
them is not an obj eel; of our prefent indication. 
There is only one which may be fuppofed to 
continue to acl: for a long time ; and that is, 
the contagion applied ; but we know nothing 
of the nature of contagion that can lead us to 
any meafures for removing or correcting it. 
We know only its effects as a fedative power 
inducing debility, or as a ferment inducing a 
tendency to putrefaction in the fluids. The 
obviating the latter will be confidered under 
our third general indication, and the former 
alone is to be confidered here. 

CCIII. 

The debility induced in fevers by contagion, 
or other caufes, appears efpecialiy in the 
weaker energy of the brain ; but in what this 
confifh, or how it may be directly reftored, 
we do not well know. As Nature, however, 
does, feemingly for this purpofe, excite the 
a£tion of the heart and arteries, we afcribe 
continuance of debility to the weaker reaction 
of the fanguiferous fyftem ; lo that the m< 
to be employed for obviating d< are 

» immediately directed to fupport and increafe 
the aftion of the heart and arteries ; and the 
remedies uled are Tonics or Stimul a n t s. 

CCIV. 



OF PHYSIC. 161 

CCIV. 

In contagious difeafes, both from the effe&s 
which appear, and from diife&ions, it is known, 
that the tone of the heart and arteries is con- 
fiderably diminifhed; and that tonic reme- 
dies, therefore, are properly indicated. 

Thefe are to be confidered as of two kinds ; 
the firft being the power of cold, the fecond 
that of tonic medicines. 

ccv. 

The power of cold, as a tonic, I have 
mentioned above (XC); and it is employed, 
in fevers, in two ways ; either as the cold 
matter is thrown into the ftomach, or as it is 
applied to the furface of the body. 

CCVI. 

As it has been fhown above, that the tonic 
power of cold can be communicated from any 
one part to every other part of the fyftem ; fo 
it will readily be allowed,that the ftomach is a 
part as fit for this communication as any 
other; and that cold drink, taken into the 
ftomach, may, therefore, prove an ufeful tonic 
in fevers. 

CCVII. 

This the experience of all ages has confirm- 
ed ; but, at the fame time, it has been fre- 
quently 



162 PRACTICE 

quently obferved, that, in certain circum- 
ftances, cold drink, taken into the ilomach, 
has proved very hurtful ; and, therefore, that 
the ufe of cold drink in fevers requires fome 
limitations. What thefe limitations mould 
be, and what are all the circumftances which 
may forbid the ufe of cold drink, is difficult 
to determine ; but it feems clearly forbidden, 
in all cafes where a phi ogi flic diathefis pre- 
vails in the fyftem, and more efpecially when 
there are topical affections of an inflammatory 
nature. 

CCVIJI. 

The other method of employing cold as a 
tonic, is, by applying it to the furface of the 
body. The application of cold air to the fur- 
face of the body, as a refrigerant power fit 
to moderate the viole'nce of reaction, I have 
fpoken of above (CXXXIII.); but probably 
it may alio be confidered here as a tonic, and 
ufeful in cafes of debility. 

CCIX. 

Not only cool air, but cold water alfo, may 
be applied to the furface of the body, as a 
refrigerant, and perhaps as a tonic. The an- 
cients frequently applied it with advantage, 
to particular parts, as a tonic ; but it is a dif- 
covery of modern times, that in the cafe of 
putrid fevers, attended with much debility, 
the body may be waflied all over with cold 
water, 

ccx. 



OF PHYSIC. 163 

CCX. 

This was firft practifedat Breflaw in Silefia, 
as appears from a diflertation, under the title 
of Epidemia verna qua; Wralijlaviam, anno 
1 737> afflixit, to be found in the appendix to 
the ABa Nat. Curiof. Vol. X. And from 
other writers we find, that the practice has 
paffed intofome of the neighbouring countries ; 
although in this ifland, id far as I know, we 
have hitherto had no experience of it. 

CCXI. 

The medicines which have been employed 
in fevers, as tonics, are various. If the Sac- 
charum Saturni has been found ufeful, it is, 
probably, as a tonic, rather than as a refriger- 
ant ; and the Ens Veneris, or other prepa- 
rations of iron which have been employed, 
can act as tonics only. The preparations of 
copper, from their effects in epilepfy, are pre- 
fumed to pofTefs a tonic power ; but, whether 
their ufe in fevers be founded upon their tonic 
or their emetic powers, may be uncertain. The 
ufe of arfenic and of alum, in intermittent 
fevers, feems manifeftly to depend upon their 
tonic power. And, upon the whole, there 
may occur cafes of continued fevers, which 
may be cured by tonics taken from the foffii 
kingdom ; but the ufe of thefe has been rare, 

sis 



164 PRACTICE 

as well as the effects uncertain ; andphyficians 
have employed, more commonly, the vege- 
table tonics. 

CCXII. 

A great variety of thefe has been employed 
in the cure of intermittent fevers ; but how 
many of them may be employed in continued 
fevers, or in what circumftances of thefe 
fevers, is not well ascertained ; and I mall 
now only confider the queftion with refpe£t 
to the moft celebrated of thefe tonics, the 
Peruvian Bark. 

CCXIII. 

This bark has been commonly confidered 
as a fpecific, or as a remedy of which the 
operation was not underflood. But it is cer- 
tainly allowable to inquire into this matter ; 
and I apprehend it may be explained. 

CCXIV. 

To this purpofe it is to be remarked, that 
as, in many cafes, the effects of the bark are 
perceived foon after its being taken into the 
ftomach, and before it can poflibly be con- 
veyed to the mafs of blood, we may conclude, 
that its effects do not arife from its operating 
on the fluids ; and muft, therefore, depend 
upon its operating on the nerves of the flom^ 

ach a 



OF PHYSIC. 165 

ach, and being thereby communicated to 
the reft of the nervous fyftem. This opera- 
tion feems to be a tonic power, the bark being 
a remedy in many cafes of debility, particu- 
larly in gangrene ; and, as the recurrence of 
the paroxyfms of intermittent fevers depends 
upon a recurrence of atony, (XXXV. and 
XXXVI.); fo probably the bark, by its 
tonic power, prevents the recurrence of thefe 
paroxyfms ; and this is greatly confirmed by 
obferving, that many other tonic medicines 
anfwer the fame purpofe. 

ccxv. 



If the operation of the bark may be thus 
explained, from its poflefling a tonic power, 
it is eafy to perceive why it is improper when 
a phlogiftic diathefis prevails ; and, from the 
fame view t we can afcertain in what cafes of 
continued fever it may be admitted. Thefe 
are either after confiderable remiffions have 
appeared, when it may be employed to pre- 
vent the return of exacerbations, on the fame 
footing that it is ufed in intermittent fevers, 
or in the advanced ftate of fevers, when all 
fufpicion of an inflammatory ftate is removed, 
and a general debility prevails in the fyftem ; 
and its being then emploved is fufficiently 
agreeable to the prefent practice. 

CCXVI. 



166 PRACTICE 



CCXVI. 

With refpett to the ufe of the bark, it is 
proper to add, that good effecls are to be ex- 
pected from it, almoft only when given in 
fubftance and in large quantity. 

CCXVII. 

Another fet of medicines to be employed 
for obviating debility and its effects, are the 
direct ftimulants (CCIII.). Thefe, in fome 
meafure, increafe the tone of the moving 
fibres ; but they are different from the tonics, 
as more dire&ly exciting and increafing the 
action of the heart and arteries. This mode 
of their operation renders the ufe of them 
ambiguous ; and when an inflammatory dia- 
thefis is prefent, as fo often happens in the be- 
ginning of fevers, the effecf s of thefe ftimu- 
lants may be very hurtful ; but it Mill re- 
mains probable, that, in the advanced ft ate 
of fevers, when debility prevails, they may 
be ufeful. 

CCXVIII. 

What are the ftimulants that may be moft 
properly employed, I am uncertain, as the 
.ife of them in this age has been rare ; but I 
am difpofed to believe that, of all kinds, wine 
is the beft. 

CCXIX. 



OF PHYSIC. 167 



CCXIX. 

Wine has the advantage of being grateful 
to the palate and flomach, and of having its 
ftimulant parts fo much diluted, that it can be 
conveniently given in (mall doles ; fo that it 
may be employed with lufficient caution ; but 
it is of little fervice, unlefs taken pretty largely. 

CCXX. 

It may be fuppofed, and on good grounds, 
that wine has an operation analogous to that 
of opium and fome other narcotic medicines. 
It may indeed be faid, that we can diftin6tly 
mark its ftimulant power only, which renders 
its efFecls in the phrenitic delirium manifeftly 
hurtful, and, in the mild delirium, depending 
on debility, as remarkably ufeful. But in all 
(his the analogy with opium is flill obvious ; 
and it is probable, that both wine and opium 
are more ufeful by their fedative and anti- 
i'pafmodic, than by their ftimulant powers. 

CCXXI. 

Thefe are the means of anfwering our fec- 
ond general indication (CXXVI. 2.) ; and I 
now proceed to the third, which is, To obviate 
or to corrctt the tendency of the fluids, to putrc- 
fatUon. 

CCXXII. 



i68 PRACTICE 



CCXXII. 

This may be done, 

1 . By avoiding any new application of pu- 
trid or putrefcent matter. 

2. By evacuating the putrid or putrefcent 
matter already prefent in the body. 

3. By correcting the putrid or putrefcent 
matter remaining in the body. 

4. By fupporting the tone of the veffels, and 
thereby refifting further putrefaction, or ob- 
viating its effects. 

CCXXIII. 



The further application of putrid or pu- 
trefcent matter may be avoided, 

1 . By removing the patient from places fill - 
ed with corrupted air. 

2 . By correcting the air from which he can- 
not be removed. 

3. By preventing the accumulation of the 
patient's own effluvia, by a conftant ventila- 
tion, and by a frequent change of bed clothes 
and body linen. 

4. By the careful and fpeedy removal of 
all excremental matters from the patient's 
chamber. 

5 . By avoiding animal food, or correcting it. 

CCXXIV. 



OF PHYSIC. 169 



CCXXIV. 

The putrid or putrefcent matter, already 
prefent in the body, may be evacuated, partly 
by evacuating frequently the contents of the 
inteft ines ; and more effectually ftill, by fup- 
porting the excretions of perfpiration and 
urine, by the plentiful ufe of diluents. 

ccxxv. 

The putrid or putrefcent matter, remaining 
in the body, may be rendered more mild and 
innocent by the ufe of diluents ; or may be 
corrected by the ufe of antifeptics. Thefe laft 
are of many and various kinds ; but which of 
them are conveniently applicable, or more 
particularly fuited to the cafe of fevers, is not 
well afcertained. Thofe moil certainly ap- 
plicable and ufeful, are acefcent aliments, acids 
of all kinds, neutral falts, and fixed air. 

CCXXVI. 

The progrefs of putrefaction may be confid- 
erably retarded, and its effects obviated, by 
fupporting the tone of the veffels ; and this 
may be done by tonic remedies ; the chief of 
which are, Cold, and Peruvian Bark, both fuf- 
ficiently treated of above, (CCV. etfeq.) 

H CCXXVII. 



tjo PRACTICE 



CCXXVII. 



I have now finifhed the consideration of the 
three general indications to be formed in the 
cure of continued fevers ; and have mentioned 
moll of the remedies which have been, upon 
any occafion, employed in this bufmefs. It 
was neceifary, in the firft place, to confider 
thefe indications and remedies feparately, and 
to explain the operation of the latter more 
generally; but, from what has been now de- 
livered, compared with what was faid above, 
concerning the difference of fevers, and the 
fignification of their feveral fymptomsin form- 
ing the prognoftic, I expecl; it will not be dif- 
ficult to aflign the indication, and to felect 
and combine the feveral remedies mentioned, 
fo as to adapt them to the feveral fpecies and 
circumftances of continued fevers. 



I think 



OF PHYSIC* 171 

i think it may be ufeful for my Readers to 
have the whole of the cure of Continued 
Fevers brought under one View, as in the 
following Table. 

in the Cure of CONTINUED FEVERS, 

The Indications are, 
I. To moderate the violence of reaction. 

Which may be done, by 
1. Diminifhing the attion of the heart and arteries, by 

A. Avoiding or moderating thofe irritations which are 

almoft conftantly applied to the body ; as, 

a. The impreflions made upon our ienfes, particu- 

larly, 
«. Increafed heat, whether arifing from 
ax. External heat,' or, 
(3(3. The accumulation of the heat of the body* 

b. The exercife of the body, 

c. The exercife of the mind, 

d. The taking in of aliment. 

e. Particular irritations arifing from 
a. The fenfe of thirft, 

0. Crudities, or corrupted humours, in the ftom- 

ach, 
y. The preternatural retention of faeces, 
$. A general acrimony of the fluids. 

B. Employing certain fedative powers ; as, 

a. Cold, 

b. Refrigerants ; the chief of which arc, 
«. Acids of all kinds, 

#. Neutral falts, 
y. Metallic lalts. 

C. Dimimfliing 
H2 



tj2 PRACTICE 

G. Diminiihing the tenfion and tone of the arterial 
fyftem, by 

a. Bloodletting, 

b. Purging. 

.£. Taking off the fpafm of the extreme veflels, by 

A. Internal means ; which are, 

a. Thole remedies which determine to the furface, as, 
a. Diluents, 

|3. Neutral falts, 
y. Sudorifics, 
$. Emetics. 

b. Thofe remedies named antifpafmodics. 

B. External means ; as, 

a. Bliftering, 

b. Warm bathing. 

II. To remove the caufes, or obviate the effeUs y 
of debility t by 

i. Supporting and increafing the a&ion of the heart 
and arteries, by 

A. Tonics, as, 

a. Cold, 

b. Tonic medicines, which are either, 
a. Foflil, as, 

oca.. Saccharum faturni, &c. or, 
(2. Vegetable, as, 
ace. Peruvian bark. 

B. Stimulants, as, 

a. Aromatics, &c. 

b. Wine. 

III. To obviate or correB the tendency of the 
Jluids to putrefaction, by 

i. Avoiding the application of putrid or putrefcent 
matter, by 

A. Removing the patient from places filled with 

corrupted air. 

B. Correcting the air, from which he cannot be 

removed. 

C. Avoiding 



OF PHYSIC. 173 

C. Avoiding the accumulation of the patient's own 

effluvia, by 

a. A conftant ventilation, 

b. Frequently changing the bed clothes and body 

linen. 

D. Removing carefully and fpeedily all excremental 

matters. 

E. Avoiding animal food, or correfting it. 

2. Evacuating the putrid or putrefcent matter already 

prefent in the body, by 

A. Evacuating frequently the inteftines. 

B. Supporting the excretions of perfpiration and 

urine, by 

a. Diluents, " 

b. Neutral falts. 

3. Correcting the putrid or putrefcent matter remaining 

in the body, by 

A. Diluents, 

B. Antifeptics, 

C. Fixed air. 

4. Refilling farther putrefaction, or obviating its ef- 

fects, by 
Supporting the tone of the veffels, by 
Tonic remedies. 



Sect. II. 

Of the CURE of Intermittent Fevers. 
CCXXVIII. 

It ftill remains to confider the cure of in- 
termittent fevers ; and, with refpecl; to thefe, 
we form alio three general indications. 

1. In the time of intermiffion, to prevent the 
recurrence of paroxyfms. 

H 3 2. In 



174 PRACTICE 

2. In the time of paroxyfms, to conduct thefe 
Jo as to obtain a final folution. of the difeafe. 

3. To take off certain circumjlances which 
might prevent the fulfilling of the two firfl indi- 
cations. 

CCXXIX. 

The firfl indication may be anfwered in 
two ways : 

1. By increafing the aftion of the heart 
and arteries fome time before the period of 
acceffion, and fupporting that increafed action 
till the period of the acceffion be over, fo as 
thereby to prevent the recurrence of the atony 
and fpafm of the extreme veffels which give 
occafion to the recurrence of paroxyfms. 

2. Without increafing the action of the 
.heart and arteries, the recurrence of parox- 
yfms may be prevented, by fupporting the 
tone of the veffels, and thereby preventing 
atony, and the consequent fpafm<. 

CCXXX. 

For the purpofe mentioned in (CCXXIX, 
1.), the a&ion of the heart and arteries may 
be increafed ; 

1. By various ftimulant remedies, inter- 
nally given, or externally applied, and that 
without exciting fweat. 

2. By the fame remedies, or others fo man- 
aged as to excite fweating, and to fupport that 

fweating 



O F P H Y S I C. 175 

fweating till the period of acceffion be for 
fome time paft. 

3. By naufeating dofes of emetics, given 
about an hour before the time of acceffion, 
thereby fupporting and increafing the tone 
and aclion of the extreme veffels. 

CCXXXI. 

The tone of the extreme veffels may be fup- 
ported without increafing the action of the 
heart and arteries (CCXXIX. 2.), by various 
tonic medicines ; as, 

1. Aftringents alone. 

2. Bitters alone. 

3. Aftringents and bitters conjoined. 

4. Aftringents and aromatics conjoined. 

5. Certain metallic tonics. 

6. Opiates. 

Laftly, An impreflion of horror. 

A good deal of exercife, and as full a diet 
as the condition of the patient's appetite and 
digeftion may allow of, will be proper during 
the time of intermiftion, and may beconfidered 
as belonging to this head. 

CCXXXII. 

OF all the tonic remedies mentioned 
(CCXXXI.), the moft celebrated^ and per- 
haps the moft certainly effectual, is the Pe- 
ruvian bark, the tonic power of which we 
have endeavoured to demonftrate above 
H 4 (CCXIVJ 



176 PRACTICE 

(CCXIV.), and have at the fame time ex- 
plained its ufe in continued fevers. 

The fame obfervation as made in CCXVI. 
is efpecially proper in the cafe of intermittents ; 
and further with refpect to thefe, the follow- 
ing obfervatios or rules are offered here. 

1. That the bark may be employed with 
fafety at any period of intermittent fevers, 
providing that, at the fame time, there be 
neither a phlogiflic diathefis prevailing in the 
fyftem, nor any confiderable or fixed con- 
geftion prefent in the abdominal vifcera. 

2. The proper time for exhibiting the bark 
in intermittent fevers, is during the time of 
intermiflion ; and where intermiflions are to 
be expetted, it is to be abftained from in 
the time of paroxyfms. 

3. In remittents, though no entire apy- 
rexia occurs, the Bark may be given during 
the remiffions ; and it mould be given, even 
though the remiffions be inconfiderable, if, from 
the known nature of the epidemic, inter- 
miflions or confiderable remiffions are not to 
be foon expected, and that great danger is 
apprehended from repeated exacerbations. 

4. In the cafe of genuine intermittents, while 
a due quantity of Bark is to be employed, the 
exhibition of it ought to be brought as near 
to the time of acceffion as the condition of the 
patient's ftomach will allow. 

5. In general, in all cafes of intermittents, 
it is not fufficient that the recurrence of parox- 
yfms be flopped for once by the ufe of the 

bark ; 



OF PHYSIC. 177 

bark ; a relapfe is commonly to be expected, 
and (hould be prevented by the exhibition of 
the bark, repeated at proper intervals. 

CCXXXIII. 

Our fecond general indication for con- 
ducting the paroxyfms of intermittent fevers, 
fo as to obtain a final folutionof the difeafe, 
may be anfwered, 

1. By exhibiting emetics during the time 
of the cold ftage, or at the beginning of the 
hot. 

2. By opiates given during the time of the 
hot ftage. 

CCXXXIV. 

The circumftances which may efpecially 
prevent the fulfilling of thofe two indications, 
and therefore give occafion to our third, are 
a phlogiftic diathefis prevailing in the fyflem, 
and congeftions fixed in the abdominal vifcera. 
The firft mufl be removed by bloodletting 
and the antiphlogiftic regimen ; the fecond, 
by vomiting and purging. 

Where thefe meafures are not immediately 
effectual, I hold it fafer to attempt the cure 
of the difeafe by the means pointed out in 
general in CCXXIX. rather than by thofe in 
article fecond of the fame paragraph. 



H 5 BOOK 




\t£p> 



of INFLAMMATIONS, or 
PHLEGMASIA. 

CHAP. I. 
o? INFLAMMATION in GENERAL. 



T., 



I. 



Of the Phenomena of Inflammation. 

ccxxxv. 

WHEN any part upon the 
furface of the body i-s affead with unufual 
rednefs, heat, pain, and tumour, we name 
the difeale an Inflammation or Phlegma- 
sia. Thefe fymptoms of inflammation are 
never eonfiderable, without the whole fyftem 
being, at the fame time, afFe&ed with pyrex- 

ia ' CCXXXVI. 



O F P H Y S I C. 179 

CCXXXVI. 

As the external, fo likewife the internal 
parts may be affe&ed with inflammation ; and 
we judge them to be To, when, together with 
pyrexia, there is a fixed pain in any internal 
part, attended with fome interruption in the 
exercife of its functions.- 

ccxxxvn: 

We judge of the prefence of inflamma- 
tion alio from the ftate of the blood .draws* 
out of the veins. When the blood, after 
cooling and concreting, mows a portion of 
the gluten feparated from the reft of the mafs, 
and lying on the furface oftHe crallamentum ; 
as fuch feparation happens in all cafes of more 
evident phlegmasia ; to, in ambiguous cafes 
we, from this appearance, joined with other 
fymptoms, infer the prefence of inflammation. 
At the fame time, it mud be obferved, that 
as feveral circumftances in bloodletting, may 
prevent this feparation of gluten from taking 
place in blood otherwife difpofed to it ; fo, 
from the abfence of fuch appearance, we can- 
not always conclude againft the prefence of 
inflammation. 

CCXXXVIII; 

I" cannot eafily give any other general i 
Hiftory of the phenomena of inflammation 
H. 6 than 



180 PRACTICE 

than what is contained in the three preceding 
paragraphs ; and the variations which may 
take place in its circumftances, will occur to 
be more properly taken notice of under the 
feveral heads of the particular genera and 
fpecies to be hereafter mentioned. I proceed, 
therefore, to inquire into the proximate caufe 
of inflammation in general. 



Sect. II. 

Of the Proximate Cause of Inflam- 
mation. 

CCXXXIX. 

The phenomena of inflammation 
(CCXXXV.) all concur in mowing, that 
there is an increafed impetus of the blood in 
the veffels of the part affected; and as, at the 
fame time, the action of the heart is not 
always evidently increafed, there is reafon to 
prefume, that the increafed impetus of the 
blood in the particular part is owing efpec- 
ially to the increafed action of the veffels of 
that part itfelf. 

CCXL. 

The caufe of this increafed action in the 
veffels of a particular part is, therefore, what 

wc 



OF PHYSIC. 181 

we are to inquire after, and to confider as the 
proximate caufe of inflammation. 

In many cafes, we can manifeftly perceive, 
that inflammation arifes from the application 
of ftimulant fubftances to the part. When 
the application of fuch ftimulants, therefore, 
is evident, we feek for no other caufe of in- 
flammation ; but as, in many cafes, fuch ap- 
plication is neither evident, nor, with any 
probability, to be fuppofed, we mull, in fuch 
cafes, feek for fome other caufe of the increaf- 
ed impetus of the blood in the veffels of the 
part. 

CCXLI. 



Many phyficians have fuppofed, that an ob- 
ftru£t.ion of the extreme veffels, any how pro- 
duced, may prove a caufe of inflammation ; 
and particularly, that this may arife from an 
obftruttion formed by a matter flopping up 
thefe veffels. But many difficulties attend 
this doctrine. 

1. The opinion feems chiefly to have ari'fen 
from the appearance of the blood defcribed in 
CCXXXVII. when the feparated gluten 
was confidered as a preternatural and morbid 
matter ; but we now know very certainly, 
that this gluten is conftantly a conftituent part 
of the human blood ; and that it is only a 
peculiar feparation of the parts of the blood 
that happens in confequence of inflammation 

and 



182 P R A C T I C E 

and fome other circumftances, which gives- 
occafion to the appearance that was falfely- 
confidered as a mark of a morbid lentor in the 
blood. 

2. There are no experiments direc"Hy in 
proof of a preternatural lentor prevailing in 
the mafs of blood;, nor is there any evidence 
of certain parts of the blood occafionally ac- 
quiring a greater denfity and force of cohefion 
than ordinary ; neither is there any proof of 
the denfer, or more coherent parts, being 
prefent in the mafs of blood in fuch greater 
proportion than ufual, as to occafion a danger- 
ous fpiffitude. The experiments of Dr. 
Browne Langrifti on this fubjeft. afford no 
conclufion, having been made on certain 
parts of the blood feparated from the reft, 
without attending to the circumftances of 
bloodletting, which very much alter the flat© 
of the feparation and concretion of the blood 
drawn out of the veins. 

3. The fuppofition of a preternatural lentor 
orvifcidity of the blood, is not well founded ; 
for it is probable, that nature has fpecially 
provided againft. a ftate of the fluids, fo in- 
compatible with the exercife of the moll im- 
portant functions of the animal economy. 
While motion continues to prevent any repa- 
ration of parts, and heat continues to preferve 
the fluidity of the more vifcid, there feems to 
be always fo large a proportion of water pref- 
ent as to give a fufficient fluidity to the whole. 
I muft own that this is not abfolutely con, 

ciufivej. 



OF PHYSIC. 183 

clufive ; but I ftill repeat it, as giving a 
probability to the general argument. 

4. In the particular cafe of inflammation, 
there are feveral circumftances which render 
it probable that the blood is then more fluid 
than ufual. 

5. I prefume that no fuch general lentor, 
as Boerhaave and his difciples have fuppofed, 
does ever take place ; becaufe if it did, it mull 
fhow more considerable effects than commonly 
appear. 

6. Befides the fuppofition of an obftru&ing 
lentor, phyficians have fuppofed, that an ob- 
ftru&ion may be formed by an impermeable 
matter of another kind, and that fuch an ob- 
ftru&ion may alfo be the caufe of inflam- 
mation. This fuppofition is what is well 
known in the fchools under the title of an 
error loci ; but it is an opinion that I can- 
not find to be at all probable ; for the mo- 
tion of the blood in the extreme veflels 
is fo weak and flow, as readily to admit a ret- 
rograde courfe of it ; and therefore, if a parti- 
cle of blood fhould happen to enter a veflel 
whofe branches will not allow of its paflage, 
it will be moved backwards, till it meet with 
a veflel fit for tranfmitting it ; and the fre- 
quent ramifications and anaftomofes of the 
extreme arteries are very favourable to this. 
I muft own indeed, that this argument is not 
abfolutely conclufive ; becaufe I allow it to 
be pretty certain, that an error loci does 
actually upon, occafion happen; but, for the 

reafons 



184 PRACTICE 

reafons I have given, it is probable that it 
feldom happens, and is therefore rarely the 
caufe of inflammation ; or if it be, that it is 
not merely by the obftru&ion that it produces ; 
as, among other reafons, I conclude particu- 
larly from the following argument. 

7. Though an obftru&ion fhouldbe fuppof- 
ed to take place, it will not be fufficient for pro- 
ducing the effefts, and exhibiting the phe- 
nomena, that appear in inflammation. The 
theory that has been commonly employed on 
this occafion is by no means fatisfying ; and,, 
in fa&, it appears, from many obfervations 
and experiments, that confiderable obftruc- 
tions may be formed, and may fubfift, with- 
out producing the fymptoms of inflammation. 

CCXLII. 

Obftru&ion, therefore, from a matter flop- 
ping up the veffels, Gaub. Pathol. 249. i. is 
not to be confidered as the primary caufe of 
inflammation; but, at the fame time, it is 
fufhciently probable, that fome degree of ob- 
ftru&ion does take place in every cafe of in- 
flammation. The diftention, pain, rednefs, 
and tumour attending inflammation, are to 
be explained only by fuppofing, that the ex- 
tremities of the arteries do not readily tranfmit 
the unufual quantity of blood impelled into 
them by the increafed action in the courfe of 
thefe veffels. Such an obftru&ion may be 
fuppofed to happen in every cafe of an in- 
creafed 



OF PHYSIC. 185 

creafed impetus of the blood ; but it is prob- 
able, that, in the cafe of inflammation, there 
is alio a preternatural refiflance to the free 
paffage of the fluids. 

CCXLIII. 

From the do6lrine of fever, we are led 
to believe, that an increafed aftion of the 
heart and arteries is not fupported for any 
length of time by any other means than a 
fpafm affe&ing the extreme veffels ; and that 
the fame fpafm takes place in inflammation, 
feems likely, becaufe that every confiderable 
inflammation is introduced by a cold ftage, 
and is accompanied with that and other cir- 
cumftances of pyrexia. It feems alfo probable, 
that fomething analogous to this occurs even 
in the cafe of thofe inflammations which appear 
lefs confiderable, and to be purely topical. 

CCXLIV. 

From all this, the nature of inflammation 
may in many cafes beexplainedin the follow- 
ing manner. Some caufes of inequality in the 
diflribution of the blood may throw an unufual 
quantity of it upon particular veffels, to which 
it mufl neceffarily prove a ftimulus. But, 
further, it is probable, that, to relieve the 
congeftion, the vis medicatrix natures increafes 
flill more the a6lion of thefe veflels; and 
which, as in all other febrile difeafes, it effe£U 

by 



186 PRACTICE 

by the formation of a fpafm on their extremi- 
ties. 

CCXLV. 

A fpafm of the extreme arteries, fupporting 
an increafed action in the courfe of them, may 
therefore be coniidered as the proximate caufe 
of inflammation ; at leafl, in all cafes not 
arifing from direct ftimuli applied ; and even 
in this cafe the ftimuli may be fuppofed to 
produce a fpafm of the extreme veffels. 

CCXLVI. 

That, in inflammation, there is the con- 
currence of a conftriction of the extreme 
veffels, with an increafed action in the other 
parts of them, feems probable, from the con- 
fideration of Rheumatifm. This is afpecies 
of inflammation which is often manifeftly pro- 
duced, either by cold applied to over diftend- 
ed veffels, or by caufes of an increafed impetus, 
and over diftention in veffels previoufly con- 
flicted. Hence the difeafe efpecially appears 
at feafons liable to frequent and confiderable 
viciffitudes of heat and cold. 

To this we may add, that the parts of the 
body moft frequently affected with inflamma- 
tion, are thofe expofed, both to over diften- 
tion, from a change in the diftribution of the 
fluids, and, at the fame time, to the immediate 
action of cold. Hence, quinfies, and pneu- 
monic 



OF PHYSIC. 187 

monic inflammations, are more frequent than 
an/ others. 

CCXLVII. 

That a fpafm of the extreme veffels takes 
place in inflammation, is to be further pre- 
fumed from what is at the fame time the ftate 
of the whole arterial fyftem. In every con- 
fiderable inflammation, though arifmg in one 
part only, an affection is communicated to the 
whole fyftem, in confequence of which an in- 
flammation is readily produced in other parts 
befide that firfl affected. This general affec- 
tion is well known among phyficians, under 
the name of the Diathesis Phlogistica. 
It appears moil commonly in perfons of the 
moft rigid fibres ; is often manifeftly induced 
by the tonic or aftringent powers of cold ; is 
increafed by all tonic and ftimulant powers 
applied to the body ; is always attended with 
a hardnefs of the pulfe ; and is mod effectual- 
ly taken off by the relaxing power of blood- 
letting. From thefe circumftances, it feems 
probable, that the diathefis phlogiftica con- 
fifls in an increafed tone, or contractility, and 
perhaps in an increafed contraction of the 
mufcular fibres of the whole arterial fyftem. 
Such a ftate of the fyftem feems often to arife, 
and fubfift for fome time, without the apparent 
inflammation of any particular part ; but fuch 
a ftate of the fyftem renders it likely, that a 
fpafm may, at the fame time, readily arife in 

any 



188 PRACTICE 

any of the extreme veffels, and a particular 
inflammation be there produced. It does, 
however, appear alfo, that the general diathe- 
fis frequently arifes from inflammation begun 
in a particular part. 

CCXLVIII. 

I have thus endeavoured, in the cafe of in- 
flammation, to explain the flate of the whole 
' fyftem, as well as that of the part more par- 
ticularly affected. The latter I have confid- 
ered as when in its firft formation ; but after 
it has fubfifted for fome time, various changes 
take place in the part affected j and of thele I 
muft now take notice. 



Sect III. 

Of the Terminations of Inflammation. 
CCXLIX. 

If an inflammation be cured while the flate 
and texture of the part remain entire the 
difeafe is faid to be terminated by Resolu- 
tion. 

This happens when the previous congeftion 
and fpafm have been in a moderate degree, 
and the increafed impetus of the blood has 
been fufficient to overcome the fpafm, to di- 
late the veffels, and to remove the congeftion, 

fo 



OF PHYSIC. 189 

fo that the part is reftored to its ordinary and 
healthy (late. 

A refolution takes place alfo when the in- 
creafed impetus of the fluids has produced an 
increafed exhalation into the adjoining cellu- 
lar texture, or an increafed excretion in fome 
neighbouring part, and has thereby relaxed 
the fpafm, and relieved the congeftion, in the 
veffels of the part more particularly affefted. 

Laftly, A refolution may take place, when 
the increafed impetus of the blood in the 
whole fyftem occafions an evacuation, which, 
though in a diftant part, may prove fufficient 
to take off the phlogiftic diathefis of the 
whole fyftem, and thereby relieve the congef- 
tion and fpafm of the particular part affedted 
by inflammation. 

CCL. 

The tumour which appears in inflamma- 
tion may be imputed in part to the congeftion 
of fluids in their proper veffels ; but is owing 
chiefly to an effufion of matter into the ad- 
joining cellular texture ; and, accordingly, tu- 
mours feldom appear but in parts adjoining 
to a lax cellular texture. . If, in this cafe, the 
matter effufed be only a larger quantity of the 
ordinary exhaling fluid, this, xvhen the free 
circulation in the veffels is reftored, will be 
readily abforbed, and the ftate of the part will 
become the fame as before. But, if the in- 
creafed impetus of the blood in an inflamed 

part, 



ie>o PRACTICE 

part, dilate the exhalant veffels to fuch a de- 
gree, that they pour out an entire ferum, this 
will not be fo readily reabsorbed ; and, from 
the experiments of Sir John Pnng:e, and 
efpecially from thofe of Mr. Gaber, MifcelL 
Taurin. Vol. II. we learn, that the (erum, 
under ftagnation, may fuffer a particular 
change, by having the gluten prefent in it 
changed into a white, opaque, moderately vif- 
cid, mild liquor, which we name Pus. 
When this change takes place in the in- 
flamed part, as it is at the fame time attended 
with an abatement of the rednefs, heat, and 
pain, which before diftinguifhed the inflam- 
mation, fo the difeafe is faid to be terminated 
by Suppuration ; and an inflamed part, 
containing a collection of pus, is called an 
Abscess. 

CCLI. 

In inflammation, the tendency of it to fup~ 
puration may be difcovered, by the long con- 
tinuance of the inflammation, without the 
fymptoms of refolution ; by fome remiflion of 
the pain of diftention ; by the pain becoming 
"of a throbbing kind, more diflin&Iy connected 
with the pulfation of the arteries ; by the 
pulfe of the arteries being fuller and fofter ; 
and often by the patient's being frequently 
afFe&ed with cold fhiverings. The period at 
which this takes place is not determined, but 
may be fometimes fooner, fometimes later. 

When 



OF PHYSIC. 191 

"When the tendency is determined, the time 
neceffary to a complete fuppuration is differ- 
ent in different cafes. 

When pus is completely formed, the paia 
in the part entirely ceafes, and a weight is felt 
in it. If the collection be formed immediate- 
ly under the fkin, the tumour becomes point- 
ed, the part becomes foft, and the fluctuation 
of the fluid within can commonly be perceiv- 
ed ; while, at the fame time, for the moft part, 
the rednefs of the fkin formerly prevailing is 
very much gone. 

CCLII. 

In abfceffes, while the pus is formed of one 
part of the matter which had been effufed, 
the other and thinner parts are reabforbed, fo 
that, in the abfcefs, when opened, a pus alone 
appears. This pus, however, is not the con- 
verted gluten alone ; for the converfion of this 
being the effect of a particular fermentation, 
which may affect; the folid fubftance of the 
part, and perhaps every folid of animal bod- 
ies ; fo it moft readily, and particularly, af- 
fects the cellular texture, eroding much of it, 
which thereby becomes a part of the pus. It 
generally happens alfo, that fome of the fmall- 
er red veffels are eroded, and thereby fome 
red blood often appears mixed with the pus in 
abfceffes. Upon the whole, the internal fur- 
face of an abfcefs is to be confidered as an ul- 
cerated part. 

CCLIII, 



192 PRACTICE 



CCLIII. 

This account of fuppuration explains, why 
an abfcefs, when formed, may either fpread 
into the cellular texture of the neighbouring 
parts ; or, by eroding the incumbent tegu- 
ments, be poured out upon the furface of the 
body, and produce an open ulcer. 

CCLIV. 

We have here given the idea of an abfcefs 
as a collection of matter following inflam- 
mation ; but the term has been applied to 
every collection of matter effufed, and chang- 
ed by flagnation in an inclofed cavity. 

The matter of abfceffes, and of the ulcers 
following them, is various, according to the 
nature of what is effufed, and which may be, 

1. A matter thinner than ferum. 

2. An entire and pure ferum. 

3. A quantity of red globules. 

4. A matter furnifhed by particular glands 
feated in the part. 

5. A mixture of matters from different 
fources, changed by peculiar fermentation. 

It is the fecond only which affords a proper 
pus ; the effufion whereof, whether in fup- 
purating parts or ulcers, feems to be the peculiar 
effect of an inflammatory flate of the veffels; 
and for this reafon it is, that, when ulcers do 
not produce a proper pus, a circumftance al- 
ways 



OF PHYSIC. 193 

ways absolutely neceffary to their healing, we, 
in many cafes, bring the ulcers to a date of 
proper iuppuration, by the application of 
ftimulants exciting inflammation, iuch as bal- 
fams, mercury, copper, &c. 

CCLV. 

When the matter effufed into the cellular 
texture of an inflamed part, is tainted with a 
putrid ferment, this produces, in the effufed 
matter, a Mate approaching more or lefs to 
that of putrefaction. When this is in a mode- 
rate degree, and affects only the fluids effufed, 
with the fubflance of the cellular texture, the 
part is faid to be affected with Gangrene ; 
but if the putrefaction affect alfo the veffds 
and mufcles of the part, the difeafe is faid to 
be a Sphacelus. 

CCLVI. 

A gangrene, and its confequences, may 
arile from a putrid ferment diffufed in the 
mafs of blood, and poured out with theferum 
effufed, which it operates upon more power- 
fully while the ferum is ftagnant, and retained 
in the heat of the body ; but it may alfo arife 
from the peculiar nature of the matter effufed 
being difpofed to putrefaftion ; as particu- 
larly feems to be the cafe of the red globules 
of the blood effufed in a large quantity. In a 
third manner alfo, a gangrene feems frequently 
1 to 



194 PRACTICE 

to arife from the violent excitement of the in- 
flammation destroying the tone of the veflels ; 
whereby the whole fluids ftagnate, and run 
into putrefaction, which taking place in any 
degree, deftroys ftill further the tone of the 
vellels, and fpreads the gangrene. 

CCLVII. 

In inflammation, the tendency to gangrene 
may be apprehended from an extreme violence 
of pain and heat in the inflamed part, and 
from a great degree of pyrexia attending the 
inflammation. 

The aclual coming on of gangrene may be 
perceived, by the colour of the inflamed part 
changing from a clear to a dark red ; by blifters 
awing upon the part; by the part becoming 
foft, flaccid, and infenfible ; and by theceafing 
of all pain while thefe appearances take place. 

As the gangrene proceeds, the colour of 
the part becomes livid, and, by degrees, quite 
black ; the heat of the part entirely ceafes ; 
the foftnefs and flaccidity of the part increafe ; 
it lofes its confiftence, exhales a cadaverous 
fmell, and may then be conlidered as affe&ed 
with fphacelus. 

CCLVIII. 

Gangrene is thus a third manner in which 
inflammation terminates ; and the fchools 
have commonly marked a fourth termination 

of 



OF P H Y S I C. 195 

of inflammation ; which is, by a fcirrhus,or an 
indolent hardnefs of the part formerly affeded 
with inflammation. This, however, is a rare 
occurrence, and does not leem to depend fo 
much upon the nature of inflammation, as 
upon the circumftances of the part afFetted. 
It is in glandular parts chiefly that fcinhofity 
is pbfcrved ; and it is probably owing to the 
parts readily admitting a ftagnation of the 
fluids. I have obferved, that inflammation 
feldom induces fcirrhus ; but that this more 
commonly arifes from other caufes ; and when 
inflammation fupervenes, which it is fooner or 
later apt to do, it does not fo commonly in- 
creafe as change the fcirrhofity into fome kind 
of abfcefs. From thefe confiderations, it does 
not leem neceffary to take any further notice 
of fcirrhus as a termination of inflammation. 



CCLIX. 

There are, however, fome other termina- 
tions of inflammation not commonly taken 
notice of, but now to be mentioned. 

One is, by the effufion of a portion of the 
entire mafs of blood, either by means of rup- 
ture or of anaflomofis, into the adjoining cel- 
lular texture. This happens efpecially m in- 
flammations of the lungs, where the effufed 
matter, by comprefling the veflels, and flop- 
ping the circulation, occafions a fatal fuffbca- 
tion ; and this is perhaps the manner in which 
I 2 pneumonic 



196 PRACTICE 

pneumonic inflammation mofl commonly 
proves fatal. 



CCLX. 

Another kind of termination is, that of cer- 
tain inflammations on the furface of the body, 
when there is poured out under the cuticle a 
fluid, which being too grofs to pafs through 
its pores, therefore feparates it from the flcin, 
and raifes it up into the form of a veficle con- 
taining the effufed fluid ; and by which efFu- 
fion the previous inflammation is taken off. 

CCLXI. 

Befide thefe already mentioned, I believe 
there is ftill another manner in which inflam- 
mation terminates. When the internal parts 
are a(Fe£ted with inflammation, there feems to 
have been almoft always upon their furface 
an exudation, which appears partly as a vifcid 
concretion upon their furface, and partly as a 
thin ferous fluid effufed into the cavities in 
which the inflamed vifcera are placed. Though 
we have become acquainted with thefe ap- 
pearances only, as very conftantly accompa- 
nying thofe inflammations which have proved 
fatal, it is however probable, that like circum- 
ftances may have attended thofe which were 
terminated by rcfolution, and may have con- 
nibuted to that event. It is in favour of this 

fuppofition 



OF PHYSIC. 197 

fuppofition that there are inflances of pneu- 
monic inflammation terminating in a hy- 
drothorax. 



T. 



IV. 



Of thl remote Causes of I nflammation. 
CCLXII. 



The remote caufes of inflammation may be 
reduced to five heads. 

1. The application of flimulant fubftances; 
among which are to be reckoned the aclion 
of fire, or burning. 

2. External violence operating mechanically 
in wounding, bruifing, comprelling, or over- 
ftretching the parts. 

3. Extraneous fubftances, lodged in any 
part of the body, irritating by their chemical 
acrimony or mechanical form, or comprefnna- 
by their bulk or gravity. 

4. Cold, in a certain degree, not fufficient 
immediately to produce gangrene. 

5. An increafed impetus of the blood deter- 
mined to a particular part. 

It will not be difficult to underftand how 

thefc remote caufes, fmgly, or in concurrence, 

produce the proximate caufe of inflammation. 

I g CCLXIIL 



198 PRACTICE 



CCLXIII. 

It does not appear, that, in different cafes 
of inflammation, there is any difference in the 
ftate of the proximate caufe, except in the de- 
gree of it ; and though fome difference of inflam- 
mation mayarife from the differenceof the re- 
mote caufes, yet this is notneceffary to be taken 
notice of here j becaufe the different appear- 
ances which attend different inflammations may 
be referred, for the moft part, to the difference 
of the part affected ; as will appear when we 
mail confider the feveral genera and fpecies 
marked in the Nofology. When I come to 
treat of thefe, I fhall find a more proper oc- 
cafion for taking notice of the different ftates 
©f the proximate, or of the differences of the 
remote caufe, than by treating of them in 
general here. 



Sect. V. 

Of the Cure of Inflammation. 

CCLXIV. 

The indications of cure in inflammation are 
different, according as it may ftill be capable of 
refohation,or may have taken a tendency to the 

feveral 



OF PHYSIC. 190 

feveral other terminations abovementioned. As 
the tendency to thefe terminations is not always 
immediately evident, it is always proper, upon 
the firft appearance of inflammation, to at- 
tempt the cure of it by refolution. For this 
purpofe, the indications of cure are, 

i. To remove the remote caufes, when 
they are evident, and continue to operate. 

2. To take off the phlogiftic diathefis 
affecting either the whole fyftcm, or the par- 
ticular part. 

3. To take of the fpafm of the particular 
part, by remedies applied either to the whole 
iyftern, or to the part itfelf. 

CCLXV. 

The means of removing the remote caufes 
will readily occur, from confidering the par- 
ticular nature and circumftances of the different 
kinds. Acrid matters muft be removed, or 
their action muft be prevented, by the ap- 
plication of correctors or demulcents. Com- 
preffmg and overftretching powers muft be 
taken away ; and, from their feveral circum- 
ftances, the means of doing fo will be obvious. 

CCLXVI. 

The means of taking off the phlogiftic 
diathefis of the fyftem are the fame with thofe 
for moderating the violence of reaftion in 

I 4 fever, 



2oo PRACTICE 



fever, which are mentioned and treated of 
from CXXVII. to CXLIX. and therefore 
need not be repeated here. I only obferve, 
that, in the uie of thole remedies, there is 
lefs occafion for any referve than in many 
cafes of fever ; and more particularly, that 
topical bleedings are here particularly in- 
dicated and proper. 

CCLXVII. 

The means of taking off the fpafm of the 
particular part are nearly the fame as thofe 
mentioned above, for taking off the fpafm of 
the extreme veffels in the cafe of fever, and 
which are treated of from CL. to CC. Only 
it is obferved here, that fome of thefe are here 
efpecially indicated, and that fome of them 
are to be directed more particularly to the 
part efpecially affefted ; the management of 
which will be more properly confidered when 
we iaall treat of particular inflammations. 

CCLXVIII. 

Wh,en a tendency to fuppuration (CCLI.) 
is diftincHy perceived, as we fuppofe it to 
depend upon the effufion of a fluid which 
cannot be eafily reabforbed, fo it becomes 
neceffary that this fluid be converted into pus, 
as the only natural means of obtaining its 

evacuation ; 



OF PHYSIC. 201 

evacuation ; and as the effufion is, perhaps, 
feldom made without fome rupture of the 
veffels, to the healing of which a pus is ab- 
folutely neceflary ; fo, in the cafe of a tendency 
to fuppuration, the indication of cure always 
is, to promote the production of a perfect 
pus as quickly as poflible. 

CCLXIX. 

For this- purpofe, various remedies, fup— 
pofed to polfefs a fpecific power, have been 
propofed ; but I can perceive no fuch power 
in any of them ; and, in my opinion, all that 
can be done is, to favour the fuppuration by 
fuch applications as may fupport a proper 
heat in the part, as by fome tenacity may 
confine the perfpiration of the part, and as, 
by an emollient quality, may weaken the 
cohefion of the teguments, and favour their - 
erofion. 

GCLXX. 

As, in the cafe of certain effufions, a fup- 
puration is not only unavoidable, but defirable, 
it may be fuppofed, that moil of the means of 
refolution formerly mentioned mould be 
avoided ; and accordingly our practice is 
commonly fo directed. But as we obferve, 
on the one hand, that a certain degree of in- 
creafed impetus, or of the original circum- 
ftances of inflammation, is requifite to pro- 
I 5 • duce 



202 PRACTICE 

duce a proper fuppuration; fo it is then espec- 
ially neceifary to avoid thofe means of rei- 
olution that may diminifh too much the 
force of the circulation. And as, on the 
other hand, the impetus of the blood, when 
violent, is found to prevent the proper fuppu- 
ration ; fo, in fuch cafes, although a tenden- 
cy to fuppuration may have begun, it may be 
proper to continue thofe means of refolution 
which moderate the force of the circulation. 
With refpecl; to the opening of abfceffes, 
xvhen completely formed, I refer to the writings 
on furgery. 

CCLXXI. 

When an inflammation has taken a tend- 
ency to gangrene, that event is to be pre- 
vented by every poffible means; and thefe 
rauft be different, according to the nature of 
the feveral caufes occafioning that tendency, 
as may be underftood from what has been al- 
ready faid of them. After a gangrene has in 
fome degree, taken place, it can be cured 
only by the leparation of the dead from the 
living parts. This, in certain circumflances, 
can be performed by the knife, and always 
mod properly, when it can be fo done. 

In other cafes, it can be done by exciting 
a fuppuratory inflammation on the verge of 
the living part, whereby its cohefion with the 
dead may be every where broken off, fo that 
the latter may fall off by itfelf. While this 

is 



OF PHYSIC. 203 

is doing, it is proper to prevent the further 
putrefaction of the part, and its fpreading 
wider. For this purpofe, various antifeptic 
applications have been propofed : But it ap- 
pears to me, that, while the teguments arc 
entire, thefe applications can hardly have any 
effect ; and, therefore, that the fundamental 
procedure muft be to fcarify the part fo as to 
reach the living fubftance, and, by the wounds 
made there, to excite the fuppuration required. 
By the fame incifions alfo, we give accefs to 
antifeptics, which may both prevent the prog- 
refs of the putrefaction in the dead, and ex- 
cite the inflammation neceffary on the verge 
of the living part. 

CCLXXIL 

When the gangrene proceeds from a lofs of 
tone ; and when this, communicated to the 
neighbouring parts, prevents that inflammation 
which, as I have faid, is neceffary to the fepa- - 
ration of the dead part from the living ; it 
will be proper to obviate this lofs of tone by 
tonic medicines given internally ; and, for 
this purpofe, the Peruvian bark has been found 
to be efpecially effectual. That this medicine 
operates by a tonic power, I have endeavour- 
ed to prove above (CCXIV.) ; and from what 
is faid in CCXV. the limitations to be ob~ 
ferved in ■emyloying.it may alfo be learned,. 
When the gangrene arifes from the violence 
of inflammation, the bark may not onlv fail 
I 6 ' 'A 



204 PRACTICE 

of proving a remedy, but may do harm ; and 
its power as atonic.is efpecially fuited to thofe 
cafes of gangrene which proceed from an orig- 
inal lofs of tone, as in the cafe of palfy and 
oedema ; or to thofe cafes of inflammation 
where a lofs of tone takes place, while the 
original inflammatory fymptoms are removed. 

CCLXXIII. 

The other terminations of inflammation 
either do not admit of any treatment except 
that of preventing them by the means of ref- 
olution ; or they belong to a treatife of 
furgery, rather than to this place. 

Having thus, therefore, delivered the general 
doclrine, I proceed now to confider the partic- 
ular genera and fpecies of inflammation. 

It has been hinted above (CCLXIII.), 
that the difference of inflammation arifes 
chiefly from the difference of the part affect- 
ed: I have therefore arranged them, as they 
are cutaneous, visceral, or articular; 
and in this order they are now to be confid- 
ered. 



- 



CHAP. 



OF PHYSIC. 205 



CHAP. II. 



or INFLAMMATION, more strictly 
CUTANEOUS. 



CCLXXIV. 

CUTANEOUS inflammations 
are of two kinds, commonly diflinguifhed by 
the names of Phlegmon and Erysipelas. 
Of the latter there are two cafes, which 
ought to be diftinguifhed by different appel- 
lations. When the difeafe is an affection of the 
fkin alone, and verylittle of the whole fyftem, 
or when the affection of the fyftem is only 
fymptomatical of the external inflammation, I 
fhallgive the difeafe the name of Erythema; 
but when the external inflammation is an ex- 
anthema, and fymptomatical of an affection 
of the whole fyftem, I fhall then name the 
difeafe Erysipelas. 

CCLXXV. 

It is the erythema only that I am tocon- 
lider here. 

For the diflinction between Erythema and 
Phlegmon, I have formerly referred to the 
characters given of them in our Nofology. See 

Synopf. 



*o6 PRACTICE 

Synopf. Nofolog. Meth. Vol. II. p. 5. gen. vii. 
fpec. 1. and 2. But \ think it proper now to de- 
liver the charatters of them more fully and ex- 
actly here, as follows. 

A Phlegmon is an inflammatory affe&ion 
of the fkin, with a fwelling, rifing generally to 
a more confiderable eminence in the middle 
of it ; of a bright red colour ; both the fwell- 
ing and colour being pretty exactly circum- 
fcribed ; the whole being attended with a pain 
of diftention, often of a Hounding or throb- 
bing kind, and frequently ending in fuppu- 
ration. 

An Erythema, Rofe, or St, Anthony's 
Fire, is an inflammatory afFe&ion of the fkin, 
with hardly any evident fwelling; of a mixed 
and not very bright red colour, readily dif- 
appearing upon prefTure, but quickly return- 
ing again ; the rednefs of no regular circum- 
fcription, but fpreading unequally, and con- 
tinuing almoft conftantly to fpread upon the 
neighbouring part ; with a pain like to that 
from burning ; producing biifters, fometimes 
of a fmall, fometimes of a larger fize ; and 
always ending in a defquamation of the fcarf 
flkin, fometimes in gangrene. 

This fubjecl: I am not to profecute here, as 
properly belonging to furgery, the bufmefs of 
which I am feldom to enter upon in this work ; 
and lhall therefore obferve only as neceflary 
here, that the difference of thefe appearances 
feems to depend on the different feat of the 
inflammation. In the phlegmon, the inflam- 
mation 



OF PHYSIC. 207 

mation feems to affect efpecially the veffels on 
the internal furface of the fkin communicating 
with the lax fubjacent cellular texture ; 
whence a more copious effufion, and that of 
ferum, convertible into pus, takes place. In 
the erythema, the inflammation feems to have 
its feat in the veffels on the external furface 
of the fkin, communicating with the rete 
mucofum, which does not admit of any 
effufion, but what feparates the cuticle, and 
gives occafion to the formation of a blifter, 
while the fmaller (ize of the veffels admits 
only of the effufion of a thin fluid, very fel- 
dom convertible into pus. 

Befides thefe differences in the circum- 
ftances of thefe two kinds of inflammation, it 
is probable that they alfo differ with refpecl; 
to their caufes. Erythema is afrie effecl; of all 
kinds of acrids externally applied to the fkin ; 
and, when arifing from an internal caufe, it 
is from an acrimony poured out on the furface 
of the fkin under the cuticle. In the phleg- 
mon, an acrimony is not commonly evident. 

CCLXXVI. 

Thefe differences in the feat and caufes of 
the phlegmon and erythema being admitted, 
it will be evident, that when an erythema 
affetts an-y internal part, it can take place in 
thofe only whofe furfaces are covered with an 
epithelion, or membrane analogous to the 
cuticle. 

CCLXXVII. 



2o8 PRACTICE 



CCLXXVII. 

The fame diftinction between the feat and 
caufes of the two difeafes will, as I judge, 
readily explain what has been delivered by 
practical writers, with refpecl; to the cure of 
thefe different cutaneous inflammations. But 
I mail not, however, profecute this here, for 
the reafon given above (CCLXXV.) ; and; 
for the fame reafon, fhall not fay any thing of 
the variety of external inflammation, that 
might otherwife be confidered here. 



CHAP. 



OF PHYSIC, 209 



CHAP. III. 



of OPHTHALMIA, or INFLAMMA- 
TION OF THE EYE. 



CCLXXVIII. 

J. HE inflammation of the eye 
may be confidered as of two kinds ; according 
as it has its feat in the membranes of the ball 
of the eye, when I would name it Ophthal- 
mia Membranarum; or as it has its feat in 
the febaceous glands placed in the tarfus, or 
edges of the eyelids, in which cafe it may be 
termed Ophthalmia Tarsi. 

Thefe two kinds are very frequently com- 
bined together, as the one may readily excite 
the other ; but they are ftill to be diftinguifh- 
ed according as the one or the other may hap- 
pen to be the primary affection, and properly as 
they often arife from different caufes. 

CCLXXIX 

The inflammation of the membranes of the 
eye affects efpecially, and mod frequently, the 
adnata, appearing in a turgefcence of its vef- 
Ms ; fo that the red veflels which are natural- 
ly there, become not only increafed in fize, 

but 



a-i'o PRACTICE 

but there appear many more than did in a 
natural ftate. This turgefcence of the veflels 
is attended with pain, efpecially upon the mo- 
tion of the ball of the eye ; and this, like ev- 
ery other irritation applied to the furface of 
the eye, produces an effufion of tears from the 
lachrymal gland. 

This inflammation commonly, and chiefly, 
affects the adnata fpread on the anterior part 
of the bulb of the eye ; but ufually fpreads al- 
fo along the continuation of that membrane 
©n the infide of the palpebral ; and, as that is 
extended on the tarfus palpebrarum, the ex- 
cretories of the febaceous glands opening there 
are alfo frequently affected. When the af- 
fection of the adnata is considerable, it is fre- 
quently communicated to the fubjacent mem- 
branes of the eye, and even to the retina itfelf, 
which thereby acquires- fo great a fenfibility, 
that the flighteft knpreffion. of light becomes 
paiufuL 

CCLXXX. 

The inflammation of the membranes- of the 
eye is in different degrees, according as the 
adnata is more or lefs- affected, or according 
as the inflammation is either of the adnata 
alone, or of the fubjacent membranes alfo ; 
aaad, upon, thefe differences, different fpecies 
have been eftablifhed, and different appella- 
tions given to them. But I fhall not, howev- 
er, profecute the confideration of thefe, being 

of 



OF PHYSIC. 211 

of opinion, that all the cafes of the Ophthal- 
mia membranarum differ only in degree, and 
are to be cured by remedies of the fame kind, 
more or lefs employed. 

The remote caufes of Ophthalmia are 
many and various ; as, 

1. External violence, by blows, contufions, 
and wounds, applied to the eyes ; and even 
very flight impulies applied^ whilft the eyelids 
are open, to the ball of the eye itfelf, are fome- 
times fufficient for the purpofe. 

2. Extraneous, bodies introduced under the 
eyelids, either of an acrid quality,, as- (moke 
and other acrid vapours, or of a bulk fufficient 
to impede the free motion of the eyelids upon 
the furface of the eyeball. 

3. The application of flrong light, or even 
of at moderate light long continued. 

4. The application of much heat, audi par- 
ticularly of that with moifture. 

5. Much exercife of the eyes in viewing 
minute objects. 

6. Frequent intoxication. 

7. Irritation from other and various difeaf- 
cs of the eyes. 

8. An acrimony prevailing in the mafs of 
blood, and deposited in the febaceous glands 
on the edges of the eyelids. 

9. A change in the dillribution. of the 
blood, whereby either a more than ufual 
quantity of blood, and with more than ufual 
jiree, is impelled into the veifels of the head, 

Of 



212 PRACTICE 

or whereby the free return of the venous blood 
from the veffels of the head is interrupted. 

10. A certain confent of the eyes with the 
other parts of the fyflem, whereby, from a 
certain ftate of thefe parts, either a fimultane- 
ous, or an altering affection of the eyes, is 
produced. 

CCLXXXI. 

The proximate caufe of Ophthalmia is not 
different from that of inflammation in general ; 
and the different circumftances of Ophthal- 
mia may be explained by the difference of its 
remote caufes, and by the different parts of 
the eye which it happens to affecl. This may 
be underflood from what has been already 
faid ; and I mail now therefore proceed to 
confider the Cure. 

CCLXXXII. 

In the cure of Ophthalmia, the firfl atten- 
tion will be always due to the removing of the 
remote caufes, and the various means neceffary 
for this purpofe will be directed by the con- 
federation of thefe caufes enumerated above. 

The Ophthalmia membranarum requires 
the remedies proper for inflammation in gen- 
eral ; and, when the deeper feated membranes 
are affected, and efpecially when a pyrexia is 
prefent, large general bleedings may be necek 
fary. But this is feldom the cafe ; as the 

Ophthalmia, 



OF PHYSIC. 213 

Ophthalmia, for the moft part, is an affection 
purely local, accompanied with little or no py- 
rexia. General bleedings, therefore, from the 
arm or foot, have little effect upon it ; and the 
cure is chiefly to be obtained by topical bleed- 
ings, that is, blood drawn from veffels near the 
inflamed part ; and opening the jugular vein 
or the temporal artery, may be confidered as 
in fome meafure of this kind. It is common- 
ly fufficient to apply a number of leeches 
round the eye ; and it is perhaps better ftill 
to draw blood from the temples, by cupping 
and fcarifying. In many cafes, a very effec- 
tual remedy is, that of fcarifying the internal 
furface of the inferiour eyelid ; and more fo 
ftill, is cutting the turgid veffels upon the ad- 
nata itfelf. 



CCLXXXIII. 



Befides bloodletting, purging, as a remedy 
fuited to inflammation in general, has been 
confidered as peculiarly adapted to inflamma- 
tions in any of the parts of the head, and 
therefore to Ophthalmia ; and it is fometimes 
ufeful ; but, for the reafons given before with 
refpett to general bleeding, purging in the 
cafe of Ophthalmia does not prove ufeful in 
any degree in proportion to the evacuation 
excited. 

CCLXXXIV. 



214 PRACTICE 



CCLXXXIV. 

For relaxing the fpafm in the part, and 
taking off the determination of the fluids to 
it, bliflering near the part has commonly 
been found ufeful. 



CCLXXXV. 

Electrical fparks taken from the eye will 
often fuddenly difcufs the inflammation of the 
adnata ; but the effect, is feldom permanent, 
and even a frequent repetition feldom gives 
an entire cure. 



CCLXXXVI. 

Ophthalmia, as an external inflammation, 
admits of topical applications. All thofe, ' 
however, that increaie the heat and relax the 
veffels of the part, prove commonly hurtful ; 
and the admiflion of cool air to the eye, the 
proper application of cold water immediately 
to the ball of the eye, and 'the application of 
various cooling and aftringent medicines, 
which at the fame time do not produce much 
irritation, prove generally ufeful ; even fpirit- 
uous liquors, employed in moderate quantity, 
have often been of fervice. 

CCLXXXVII. 



O F P H Y S I C, W5 



CCLXXXVII. 

In the cure of Ophthalmia, much care is 
requifite to avoid all irritation, particularly 
that of light ; and the only fafe and certain 
means of doing this, is by confining the pa- 
tient to a very dark chamber. 

CCLXXXVIII. 

Thefe are the remedies of the Ophthalmia 
membranarum ; and in the Ophthalmia tarfi, 
fo far as it is produced by the Ophthalmia 
membranarum, the fame remedies may be 
necefTary. As, however, the Ophthalmia 
tarfi may often depend upon an acrimony de- 
pofited in the febaceous glands of the part, fo 
it may require various internal remedies ac- 
cording to the nature of the acrimony in fault ; 
for which I muft refer to the confideration of 
fcrophula, fyphilis, or other difeafe? with 
which this Ophthalmia may be connected ; 
and when the nature of the acrimony is not 
afcertained, certain remedies, more generally 
adapted to the evacuation of acrimony, fuch, 
for inftance, as mercury, may be employed. 

CCLXXXIX. 

In the Ophthalmia tarfi, it almoft conftant- 
ly happens, that fome ulcerations are formed 
on the tarfus. Thefe require the application 

of 



«i6 PR A C T I C E 

of mercury or copper, either of which may by 
itfelf fometimes entirely cure the affection ; 
and thefe may even be ufeful when the difeafe 
depends upon a fault of the whole fyflem. 

ccxc. 

Both in the Ophthalmia membranarum, 
and in the Ophthalmia tarfi, it is neceflary to 
obviate that gluing or flicking together of the 
eyelids which commonly happens in fleep; 
and this may be done by infinuating a little 
of any mild un&uous medicine of fome tenac- 
ity between the eyelids before the patient 
fhall go to fleep. 



CHAP. 



OF PHYSIC. 217 

CHAP. IV. 

of PHRENSY, or PHRENITIS. 

CCXCI. 

1 HIS difeafe is an inflamma- 
tion of the parts contained in the cavity of the 
cranium ; and may affe6r. either the mem- 
branes of the brain, or the fubftance of the 
brain itfelf. Nofologifts have apprehended, 
that thefe two cafes might be diftinguiihed by 
different fymptoms, and therefore by different 
appellations ; but this does not feem to be 
confirmed by obfervation and diffe&ion ; and 
therefore I fhall treat of both cafes under the 
title of Phrenfy, or Phrenitis. 

CCXCII. 

An idiopathic phrenfy is a rare occurrence, 
a fympathic more frequent ; and the ascer- 
taining either the one or the other is, upon 
many occafions, difficult. Many of the fvnrp- 
toms by which the difeafe is nioft commonly 
judged to be prefent, have appeared, when, 
from certain confiderations, it was prefumed," 
and even from diffeftion it appeared, that 
K there 



2i8 PRACTICE 

there had been no internal inflammation; and, 
on the other hand, difTc&ions have mown, 
that the brain had been inflamed, when few 
of the peculiar fymptoms of phrenfy had be- 
fore appeared. 

CCXCIII. 

The fymptoms by which this difeafe may be 
molt certainly known are, a vehement pyrexia, 
a violent deep feated headach, a rednefs and 
turgefcence of the face and eyes, an impatience 
of light or noife, a conflant watching, and 
a delirium impetuous and furious. Some 
nofologiils have thought thefe fymptoms pecu- 
liar to an inflammation of the membranes, 
and that the inflammation of the fubftance of 
the brain was to be diflinguifhed by fome de- 
gree of coma attending it. It was for this 
reafon that in the Nofology I added the Ty- 
phomania to the character of Phrenitis ; but, 
upon farther reflection, I find no proper 
foundation for this ; and, if we pafs from the 
characters above delivered, there will be no 
means of fixing the variety that occurs. 

I am here, as in other analogous cafes, of 
opinion, that the fymptoms above mentioned 
of an acute inflammation, always mark in- 
flammations of membranous parts; and that an 
inflammation of the parenchyma or fubftance 
of vifcera, exhibits, at lead commonly, a more 
onic affection. 

CCXCIV, 



O F P H Y S I C. 219 



CCXCIV. 

The remote caufes of phrenfy, are all thofe 
which direclly flimulate the membranes, or 
fubflance of the brain ; and particularly all 
thofe which increafe the impetus of the blood 
in the veffels of the brain. Among thefe the 
expofure of the naked head to the direcl rays 
of a very warm fun, is a frequent caufe. The 
paflions of the mind, and certain poifons, are 
amongft the remote caufes of phrenfy ; but in 
what manner they operate, is not well under- 
stood. 

ccxcv. 

The cure of phrenfy is the fame with that 
of inflammation in general ; but in phrenfy 
the mod powerful remedies are to be imme- 
diately employed. Large and repeated blood- 
letting is efpecially neceffary ; and the blood 
mould be drawn from veffels as near as pof- 
fible to the part affetted. The opening of 
the temporal artery has been recommended, 
and with fome reafon ; but the practice is 
attended with inconvenience ; and I apprehend, 
that opening the jugular veins may prove 
■ effe&ual ; but, at the fame time, it will 
euerally proper to draw blood from the 
temples by cupping and fcarifying. 

K 2 CCXCVI. 



22o PRACTICE 



CCXCVI. 

It is probable, that purging, as it may 
operate by revulfion, may be of more ufe in 
this thaninfome other inflammatory affections. 

For the fame purpofe of revulfion, warm 
pediluvia are a remedy ; but, at the fame 
time, fomewhat ambiguous. The taking ofF 
the force of the blood in the veffels of the head 
by an erett pofture, is generally ufeful. 

CCXCVII. 

Shaving of the head is always proper and 
neceffary for the admiffion of other remedies. 
Bliftering is commonly ufeful in this difeafe, 
but chiefly when applied near to the part 
affe&ed. 

CCXCVIII. 

Every part of the antiphlogiftic regimen is 
here neceffary, and particularly the admiffion 
of cold air. Even cold fubftances, applied 
clofc to the head, have been found fafe 
and highly ufeful ; and the application of fuch 
refrigerants as vinegar, is certainly proper. 

CCXCIX. 

It appears to me certain, that opiates are 
hurtful in every inflammatory (late of the 

brain ; 



O F P H Y S I C. 221 

brain ; and it is to be obferved, that, from 
the ambiguity mentioned in CCXCH. the 
accounts of practitioners, with regard to the 
juvantia and laedentia in this difeafe, are of 
very uncertain application. 



K a CHAP. 



222 PRACTICE 



CHAP. V. 

of the QUINSY, or CYNANCHE. 
CCC. 

1 HIS name is applied to 
every inflammation of the internal fauces ; 
hut thefe inflammations are different, accord- 
ing to the part of the fauces which may be 
arretted, and according to the nature of the 
inflammation. In the Nofology, therefore, 
after giving the character of the Cynanche as 
a genus, I have diflinguifhed five different 
fpecies, which mud here likewife be feparate- 
ly considered. 

Sect. I. 

Of the Cynanche Tonsillaris. 

CCCI. 

THIS is an inflammation of the mucous 
membrane of the fauces, affefting efpecially 
that congeries of mucous follicles which forms 
the tonfils, and fpreading from thence along 
the velum and uvula, fo as frequently to affedt 
every part of the mucous membrane. 

CCCII. 



OF PHYSIC. 223 



CCCII. 

The difeafe appears by fome tumour, fome- 
times confiderable, and by a rednefs of the 
parts ; is attended with a painful and difficult 
deglutition ; with a pain fomctime mooting 
into the ear ; with a troublefome clamminefs 
of the mouth and throat ; with a frequent, but 
difficult, excretion of mucous ; and the whole 
is accompanied with a pyrexia. 

CCCIII, 



This fpecies of quinfy is never contagious. 
It terminates frequently by refolution, fome- 
times by fuppuration, but hardly ever by gan- 
grene ; although in this difeafe fome floughy 
ipots, commonly fuppofed to be forerunners 
of gangrene, fometimes appear upon the 
fauces. 



CCCIV. 

This difeafe is commonly occafioned by 
cold externally applied, particularly about 
the neck. It affecls efpecially the young and 
fanguinc, and a difpofition to it is often ac- 
quired by habit ; fo that from every confider- 
able application of cold to any part of the 
body, this difeafe is readily induced. It 
K 4 occurs 



224 PRACTICE 

occurs efpecially in fpring and autumn, when 
viciffitudes of heat and cold frequently take 
place. The inflammation and tumour are 
commonly at firft moil confiderable in one 
tonfil ; and afterwards, abating in that, in- 
creafe in the other. 



cccv. 

In the cure of this inflammation, fome 
bleeding may be proper; but large general 
bleedings will feldom be neceffary. The 
opening of the ranular veins feems to be an 
infignificant remedy ; and leeches fet upon 
the external fauces are of more efficacy. 

CCCVI. 

At the beginning of the difeafe, full vom- 
iting has been frequently found to be of 
great fervice. 

CCCVII. 

This inflammation may be often relieved 
by moderate aftringents, and particularly by 
acids applied to the inflamed parts. In many 
cafes, however, nothing has been found to 
give more relief than the vapour of warm 
water received into the fauces by a proper 
apparatus, 

CCCVIII. 



OF PHYSIC. 225 

CCCVIII 

The other remedies of this difeafe are rube- 
facient or bliftering medicines, applied ex- 
ternally to the neck ; and, with thefe, the 
employment of antiphlogiftic purgatives, as 
well as every part of the antiphlogiftic regi- 
men, excepting the application of cold. 

CCCIX. 

This difeafe, as we have faid, often ter- 
minates by refolution, frequently accompani- 
ed with fweating ; which is therefore to be 
prudently favoured and encouraged, 

cccx. 

When this difeafe fhall have taken a tend- 
ency to fuppuration, nothing will be more 
ufeful, than the frequent taking into the 
fauces the (teams of warm water. When the 
abfcefs is attended with much fwelling, if it 
break not fpontaneoufly, it mould be opened 
by a lancet ; and this does not require much 
caution, as even the inflammatory flate may 
be relieved by fome fcarification of the tonfils. . 
I have never had occafion to fee any cafe re- 
quiring bronchotomy. 

K /v S e c t, II- 



226 PRACTICE 



T. 



II. 



Of the Cynanche Maligna, 

CCCXL 

THIS is a contagious difeafe,feldomfporad- 
ic, and commonly epidemic. It attacks per- 
fons of all ages, but more commonly thole in 
a young and infant ftate. It attacks perfons 
of every conflitution when expofed to the 
contagion, but moil readily the weak and 
infirm. 

CCCXII. 

This difeafe is ufually attended with a con- 
fiderable pyrexia ; and the fymptoms of the 
acceffion of this, fuch as frequent cold fhiver- 
ings, ficknefs, anxiety, and vomiting, are often 
the firft appearances of the difeafe. About 
the fame time, a ftiffnefs is felt in the neck, 
with fome uneafinefs in the internal fauces, 
and feme hoarfenefs of the voice. The inter- 
nal fauces, when viewed, appear of a deep red 
colour, with fome tumour ; but this la ft is 
feldom confiderable, and deglutition is feldom 
difficult or painful. Very foon, a number of 
white or alh coloured fpots appear upon the 

"inflamed 



OF PHYSIC. 227 

inflamed parts. Thefe fpots fpread and unite, 
covering almoft the whole fauces with thick 
/loughs ; which falling off, difcover ulcera- 
tions. While thefe fymptoms proceed in the 
fauces, they are generally attended with a co- 
ryza, which pours out a thin acrid and fetid 
matter, excoriating the noflrils and lips. 
There is often alfo, especially in infants, a fre- 
quent purging ; and a thin acrid matter flows 
from the anus, excoriating this and the neigh- 
bouring parts. 

CCCXIII. 

With thefe fymptoms, the pyrexia proceeds 
with a fmall, frequent, and irregular pulfe ; 
and there occurs a manifeft exacerbation every 
evening, and fome remiflion in the mornings. 
A great debility appears in the animal func- 
tions ; and the fenforium is affected with de- 
lirium, frequently with coma. 

CCCXIV. 

On the fecond day, or fometimes later, 
efflorefcences appear upon the {kin, which are 
•fometimes in fmall points hardly eminent ; 
but, for the moft part, in patches of a red col- 
our, fpreading and uniting fo as to cover the 
whole flcin. They appear firfl about the 
face and neck, and in the courfe of fome days 
fpread by degrees to the lower extremities. 
The icarlet rednefs is often confiderable on 
K 6 the 



228 PRACTICE 

the hands and extremities of the fingers, winch 
feel ftiff and fwelled. This eruption is often 
irregular, as to the time of its appearance, as 
to its ileadinefs, and as to the time of its 
duration. It ulually continues four days^ 
and goes off by fome defquamation of the 
cuticle ; but neither on its firft appearance, 
nor on its defquamation, does it always pro- 
duce a remimon of the pyrexia, or of the other 
iymptoms. 

ccexv. 

The progrefs of the difeafe depends on the 
of the fauces and of the pyrexia. When 
the ulcers on the fauces, by their livid and 
black colour, by the fetor of the breath, and 
by many marks of acrimony in the fluids, 
mow a tendency to gangrene, this takes place 
to a confiderabie degree ; and, the fymptoms 
of a putrid fever conftantly increafing, the 
patient dies, often on the third day, fome- 
times later, but for the moil part before the 
feventh. The acrimony poured out from the 
difcafed fauces muft necenarily, in part, pafs 
into the pharynx, and there fpread the in- 
fection into the ccfophagus, and fome times 
through the whole of the alimentary canal, 
propagating the putrefaction, and often ex- 
haufting the patient by a frequent diarrhoea.. 

The acrid matter poured out in the fauces 
being again abforbed, frequently occafions 
large fwellings of the lymphatic glands about 

the 



OF PHYSIC. 229 

the neck, and fometimes to fuch a degree a* 
to occafion fuffocation. 

It is feldom that the organs of refpiratiore 
efcape entirely unhurt, and very often the in- 
flammatory affedtion is communicated to them. 
From diffections it appears, that, in the Cyn- 
anche maligna, the larynx and trachea are 
often affected in the fame manner as in the 
Cynanche trachealis ; and it is probable, that, 
in confequence of that affection, the Cynanche 
maligna often proves fatal by fuch a fudden 
fuffocation as happens in the proper Cynanche 
trachealis ; but there is reafon to fufpecl; that 
upon this fubjecl; diffettors have not always 
diftinguifhed properly between the two dif- 
eales. 

CCCXVI. 

Thefe are the feveral fatal terminations of • 
the Cynanche maligna ; but they do not always 
take place. Sometimes the ulcers of the 
fauces are of a milder nature ; and the fever 
is more moderate, as well as of a lefs putrid 
kind. And when, upon the appearance of 
the efflorefcence on the ikin, the fever fuffers 
a remiilion ; when the efflorefcence continues 
for three or four days, till it has fpread over 
the whole body, and then ends by a defqua- 
mation, giving a further remiilion of the fe- 
ver ; this often entirely terminates, by gentle 
fweats, on or before the feventh day ; and the 
6 reft of the difeafe terminates in a few days 

more, 



2 3 o PRACTICE 

more, by an excretion of floughs from the 
fauces, while fleep, appetite, and the other 
marks of health, return. 

From what is faid in this and the preceding 
paragraph, the prognoftics in this difcafe may 
be readily learned. 



CCCXVII. 



In the cure of this difeafe, its feptic tend- 
ency is chiefly to be kept in view. The de- 
bility, with which it is attended, renders all 
evacuations by bleeding and purging improp- 
er, except in a few inftances where the debil- 
ity is lefs, and the inflammatory fymptoms 
more confiderable. The fauces are to be pre- 
ferred from the effects of the acrid matter 
poured out upon them, and are therefore to 
be frequently wafhed out by antifeptic gar- 
gles or injections ; and the feptic tendency 
of the whole fyftem ftiould be guarded againfl 
and corrected by internal antifeptics, efpec- 
ially by the Peruvian bark given in fubftance, 
from the beginning, and continued through 
the courfe of the difeafe. Emetics, both by 
vomiting and naufeating, prove ufeful, efpec- 
ially when employed early in the difeafe. 
When any confiderable tumour occurs, blif- 
ters applied externally will be of fervice, and, 
in any cafe, may be fit to moderate the in- 
ternal inflammation. 

Sect. 



OF PHYSIC, 231 

Sect. III. 
Of the Cynanche Trachealis. 

CCCXVIII. 

THIS name has been givento an inflam- 
mation of the glottis, larynx, or upper part of 
the trachea, whether it affecl: the membranes 
of thefe parts, or the mufcles adjoining. It 
may arife firft in thefe parts, and continue to 
fubfift in them alone ; or it may come to af- 
fett thefe parts from the Cynanche tonfillaris 
or maligna fpreading into them. 

CCCXIX. 

In either way it has been a rare occurrence, 
and few inftances of it have been marked and 
recorded by phyficians. It is to be known by 
a peculiar ringing found of the voice, by diffi- 
cult refpiration, with a lenfe of ftraitening 
about the larynx, and by a pyrexia attending 
it. 

CCCXX. 

From the nature of thefe fymptoms, and 
from the dine&ion of the bodies of perfons 
who had died of this difeafe, there is no doubt 

of 



332 P R A C T I G E 

of its being of an inflammatory nature. It 
does not, however, always run the courlc of 
inflammatory affections ; but frequently pro- 
duces fuch an obftru6lion of the pailage of the 
air, as fuffocates, and thereby proves. i'udden- 
\y fatal. 

CCCXX1. 

If we judge rightly of the nature of this 
difeafe, it will be obvious, that the cure of it 
requires the moil powerful remedies of in- 
flammation, to be employed upon the very 
firft appearance of the fymptoms. When a 
fuffocation is threatened, whether any reme- 
dies can be employed to prevent it, we have 
not had experience to determine. 

CCCXXII. 

The accounts which books have hitherto 
given us of inflammations of the larynx, and 
the parts connected with it, amount to what 
we have now faid ; and the inftances record- 
ed have almoft; all of them happened in adult 
perfons j but there is a peculiar affeclion of 
this kind happening efpecially to infants, 
which till lately has been little taken notice 
of. Dr. Home is the firft who has given any 
diftincl: account of it ; but, fmce he wrote, 
feveral other authors have taken notice of it. 
(fee Michaelis De angina fiolypofa five r»v 
branacia, Argentorali 1778) ; and hav 

different 



OF PHYSIC. 233 

different opinions with regard to it. Con- 
cerning this diverfity of opinions I (hall not 
at prefent inquire ; but (hall deliver the hif- 
tory and cure of this difeafe, in fo far as thefe 
have arifen from my own obfervation, from 
that of Dr. Home, and of other fkilful per- 
fons in this neighbourhood. 

CCCXXIII. 

This difeafe feldom attacks infants till after 
they have been weaned. After this period, 
the younger they are, the more they are liable 
to it. The frequency of it becomes lefs as 
children become more advanced ; and there 
are no inflances of children above twelve 
years of age being affe&ed with it. It attacks 
children of the midland countries, as well as 
thofe who live near the fea. It does not ap- 
pear to be contagious, and its attacks are fre- 
quently repeated in the lame child. It is oft- 
en manifeftly the effect of cold applied to the 
body ; and therefore appears moft frequently 
in the winter and fpring feafons. It very 
commonly comes on with the ordinary fymp- 
toms of a catarrh ; but fometimes the peculiar 
fymptoms of the difeafe fhow tliemfelves at 
the very firft. 

CCCXXIV. 

Thefe peculiar fymptoms are the follow- 
ing : A hoarfenefs, with fome fhrillnefs and 

ringing 



234 PRACTICE 

ringing found, both in fpeaking and cough- 
ing, as if the noife came from a brazen tube. 
At the fame time there is a fenfe of pain about 
the larynx, fome difficulty of refpiration, with 
a whizzing found in infpiration, as if the paf- 
fage of the air were ftraitened. The cough 
which attends it, is commonly dry ; and, if 
any thing be (pit up, it is a matter of a puru- 
lent appearance, and fometimes films refcm- 
bling portions of a membrane. Together 
with thefe fymptoms, there is a frequency of 
pulfe, a reflleflhefs, and an uneafy fenfe of heat. 
When the internal fauces are viewed, they are 
fometimes without any appearance of inflam- 
mation ; but frequently a rednefs, and even 
fwelling, appear ; and fometimes in the f.» 
there is an appearance of matter like to that re- 
jected by coughing. With the fymptoms 
now defcribed, and particularly with great 
difficulty of breathing, and a fenfe of flran- 
gling in the fauces, the patient is fometimes 
fuddenly taken off. 

ccexxv. 

There have been many difTeclions made of 
infants who had died of this difeafe ; and al- 
moft conflantly there has appeared a preter- 
natural membrane lining the whole internal 
furface of the upper part of the trachea, and 
extending in the fame manner downwards in- 
to fome of its ramifications. This preternat- 
ural membrane may be eafily feparated, and 

fometimes 



OF PHYSIC. 235 

fometimes has been found feparated in part, 
from the fubjacent proper membrane of the 
trachea. This laft is commonly found entire, 
that is, without any appearance of erofion or 
ulceration ; but it frequently Ihows the veft- 
iges of inflammation, and is covered by a 
matter refembling pus, like to that rejected by 
coughing ; and very often a matter of the fame 
kind is found in the bronchia;, fometimes in 
confiderable quantity, 

CCCXXVI. 

From the remote caufes of this difeafe ; 
from the catarrhal fymptoms commonly at- 
tending it ; from the pyrexia conftantly pref- 
ent with it ; from the fame kind of preternat- 
ural membrane being found in the trachea 
when the cynanche maligna is communicated 
to it ; and from the veftiges of inflammation 
on the trachea discovered upon difleclion ; 
we muff conclude, that the difeafe confifls in 
an inflammatory affe&ion of the mucous 
membrane of the larynx and trachea, produc- 
ing an exudation analogous to that found on 
the furface of inflamed vifcera, and appearing 
partly in a membranous cruft, and partly in 
a fluid refembling pus. 

CCCXXVII. 

Though this difeafe manifeftly confifls in 
an inflammatory affe&ion, it does not com- 
monly 



23 6 PRACTICE 

monly end either in fuppuration or gangrene. 
The peculiar and troublefome circumrtance 
of the difeafe feems to confifl in a fpafm of 
the mufcles of the glottis, which, by inducing a 
fufFocation, prevents the common confequen- 
ces of inflammation. 

CCCXXVIII. 

When this difeafe terminates in health, it is 
by a refolution of the inflammation, by aceaf- 
ing of the fpafm of the glottis, by an expecto- 
ration of the matter exuding from the trachea, 
and of the crufts formed there ; and frequent- 
ly it ends without any expectoration, or at 
lead with fuch only as attends an ordinary 
catarrh. 

CCCXXIX. 

When the difeafe ends fatally, it is by a 
fuffocation ; feemingly, as we have faid, de- 
pending upon a fpafm affe&ing the glottis ; 
but fometimes, probably, depending upon a 
quantity of matter filling the bronchia?. 

ccexxx. 

As we fuppofe the difeafe to be an inflam- 
matory affeaion, fo we attempt the cure of it 
by the ufual remedies of inflammation, and 
which for the moll part I have found effec- 
tual. Bleeding, both general and topical, has 

often. 



OF PHYSIC. * 37 

often given immediate relief; and, by being 
repeated, has entirely cured the difeafe. Blif- 
tering alio, near to the part afFe6led, has been 
found ufeful. Upon the firft attack of the 
difeafe, vomiting, immediately after bleeding, 
feems to be of confiderable ufe, and fometimes 
fuddenly removes the difeafe. In every ftage 
of the difeafe, the antiphlogiftic regimen is 
neceffary, and particularly the frequent ufe of 
laxative glyfters. Though we fuppofe that a 
fpafm affe&ing the glottis is often fatal in this 
difeafe, I have not found antifpafmodic medi- 
cines to be of any ufe. 



Sect. IV. 

Of the CYNANCHE PHARYNGiEA. 

CCCXXXI. 

IN the Cynanche ton fill aris, the inflamma- 
tion of the mucous membrane often fpreads 
upon the pharynx, and into the beginning of 
the aefophagus, and thereby renders degluti- 
tion more difficult anduneafy ; but fuch a cafe 
does not require to be diftinguiihed as a dif- 
ferent fpecies from the common Cynanche 
tonfillaris ; and only requires that bloodlet- 
ting, and other remedies, mould be employed 
with greater diligence than in ordinary cafes. 

We 



238 PRACTICE 

We have never feen any cafe in which the in- 
flammation began in the pharynx, or in which 
this part alone was inflamed ; but practical 
writers have taken notice of fuch a cafe ; and 
to them, therefore, I muft refer, both for the 
appearances which diftinguifh it, and for the 
method of cure. 



Sect. V. 
Of the Cynanche Parotide a. 

CCCXXXII. 

THIS is a difeafe known to the vulgar, and 
among them has got a peculiar appellation in 
every country of Europe ; but has been little 
taken notice of by medical writers. It is often 
epidemic, and manifeftly contagious. It 
comes on with the ufual fymptoms of pyrexia, 
which is foon after attended with a confider- 
able tumour of the external fauces and neck. 
This tumour appears firft as a glandular move- 
able tumour at the corner of the lower jaw ; 
but the (Welling foon becomes uniformly dif- 
fufed over a great part of the neck, fometimes 
on one fide only, but more commonly on both. 
The fwelling continues to increafe till the 
fourth day ; but from that period it declines, 
and in a few days more paffes off entirely. 

As 



OF PHYSIC. 239 

As the fwelling of the fauces recedes, fome tu- 
mour affects the tefticles in the male fex, or 
the breaftsin the female. Thefe tumours are 
fometimes large, hard, and fomewhat painful ; 
but, in this climate, are feldom either very 
painful or of long continuance. The pyrexia 
attending this difeafe is commonly flight, and 
recedes with the fwelling of the fauces ; but 
fometimes, when the fwelling of the tefticles 
does not lucceed to that of the fauces, or when 
the one or the other has been fuddenly re- 
preffed, the pyrexia becomes more considera- 
ble, is often attended with delirium, and has 
fometimes proved fatal. 

CCCXXXIII. 

As this difeafe commonly runs its courfe 
without either dangerous or troublefome 
fymptoms, fo it hardly requires any remedies. 
An antiphlogiftic regimen, and avoiding cold, 
are all that will be commonly neceifary. But 
when upon the receding of the fwellings of the 
tefticles in males, or of the breads in females, 
the pyrexia comes to be confiderable, and 
threatens an affection of the brain, it will be 
proper, by warm fomentations, to bring back 
the fwelling ; and, by vomiting, bleeding, or 
bliftering, to -obviate the confequences of its 
abfence. 



C H A P. 



Ho PRACTICE 



CHAP. VI. 



of PNEUMONIA, or PNEUMONIC 
INFLAMMATION. 



CCCXXXIV. 

UNDER this title I mean to 
comprehend the whole of the inflammations 
affecting either thevifcera of the thorax or the 
membrane lining the interior furface of that 
cavity ; for neither do our diagno flics ferve 
to afcertain exaclly the feat of the difeafe ; 
nor does the difference in the feat of the dif- 
eafe exhibit any confiderable variation in the 
ftate of the fymptoms, nor lead to any differ- 
ence in the method of cure. 

CCCXXXV. 

Pneumonic inflammation, however various 
in its feat, feems to me to be always known and 
diflinguifhed by the following fymptoms ; 
pyrexia, difficult breathing, cough, and pain 
in fome part of the thorax. But thefe fymp- 
toms are, on different occafions, varioufly 
modified. 

CCCXXXVI. 



OF PHYSIC. 241 



CCCXXXVI. 

The difeafe almoft always comes on with a 
cold ftage, and is accompanied with the other 
fymptoms of pyrexia ; though, in a few in- 
ftances, the pulfe may not be more frequent, 
nor the heat of the body increafed beyond 
what is natural. Sometimes the pyrexia is 
from the beginning accompanied with the oth- 
er fymptoms ; but frequently it is formed for 
fome hours before the other fymptoms become 
confiderable, and particularly before the pain 
be felt. For the molt part, the pulfe is fre- 
quent, full, flrong, hard, and quick ; but, in a 
few inftances, efpecially in the advanced flate 
of the difeafe, the pulfe is weak and foft, and 
at the fame time irregular. 

m 

CCCXXXVII. 

The difficulty of breathing is always pref- 
ent, and mod confiderable in infpiration ; both 
becaufe the lungs do not eafily admit of a full 
dilatation, and becaufe the dilatation aggra- 
vates the pain attending the difeafe. The 
difficulty of breathing is alfo greater when the 
patient is in one poflure of his body rather 
than another. It is generally greater when 
he lies upon the fide affected ; but fometimes 
the contrary happens. Very often the patient 
cannot lie eafy upon either fide, finding eafe 
only when lying on his back ; and fometimes 
L he 



242 PRACTICE 

he cannot breathe eafily, except when in fome- 
what of an erect, pofture. 

CCCXXXVIII. 

A cough always attends this difeafe ; but, 
in different cafes, is more or lefs urgent and 
painful. It is fometimes dry, that is, without 
any expectoration, efpecially in the beginning 
of the difeafe ; but more commonly it is, even 
from the firft, moid, and the matter fpit up 
various both in confidence and colour ; and 
frequently it is {freaked with blood. 

cccxxxix. 

The pain attending this difeafe^ is, in dif- 
ferent cafes, felt in different parts of the tho- 
rax, but molt frequently in one fide. It has 
been faid to affeft the right fide more fre- 
quently than the left ; but this is not certain ; 
while, on the other hand, it is certain, that the 
left fide has been very often afFefted. The 
pain is felt fometimes as if it were under the 
fternum ; fometimes in the back between the 
moulders ; and, when in the fides, its place 
has been higher t>r lower, more forward or 
backward; but the place of all others moft 
frequently affeaed, is about the fixth or fev- 
enth rib, near the middle of its length or a 
little more forward. The pain is often fevere 
•md pungent ; but fometimes more dull and 
obtufe, with a fenfe of weight rather than of 
tJULU * pam. 



OF PHYSIC. 243 

pain. It is moft efpecially fevcre and pun- 
gent when occupying the place laft mentioned. 
For the moft part it continues fixed in one 
place ; but fometimes moots from the fide to 
the fcapula on one hand, or to the flernum 
and clavicle on the other. 

CCCXL. 

The varying flate of fymptoms now men- 
tioned does not always afcertain precifely the 
feat of the difeafe. To me it feems probable, 
that the difeafe is always feated, or at leaft be- 
gins, in fome part of the pleura ; taking that 
membrane in its greateft extent, as now com- 
monly underftood ; that is, as covering not 
only the internal furface of the cavity of the 
thorax, but alfo as forming the mediaftinum, 
and as extended over the pericardium and 
over the whole furface of the lungs. 

CCCXLI. 

There is, therefore, little foundation for dif- 
tinguifhingthis difeafe by different appellations 
taken from the part which may be fuppofed 
to be chiefly affected. The term Pleuri- 
fy, might with propriety be applied to everv 
cafe of the difeafe ; and has been verv im- 
properly limited to that inflammation which 
begins in, and chiefly affects, the pleura coflalis. 
I have no doubt that fuch a cafe does truly 
occur i but, at the fame time, I apprehend it 
L 2 to 



244 PRACTICE 

to be a rare occurrence ; and that the difeafe 
much more frequently begins in, and chiefly 
affects, the pleura inverting the lungs, pro- 
ducing all the fymptoms fuppofed to belong 
to what has been called the Pleuritis vera. 

CCCXLII. 

Some phyficians have imagined, that there 
is a cafe of pneumonic inflammation particu- 
larly entitled to the appellation of Peripneu- 
mony ; and that is, the cafe of an inflamma- 
tion beginning in the parenchyma or cellular 
texture of the lungs, and having its feat chief- 
ly there. But it Teems to me very doubtful, 
if any acute inflammation of the lungs, or any 
difeafe which has been called Peripneumony, 
be of that kind. It feems probable, that ev- 
ery acute inflammation begins in membranous 
parts ; and, in every diffeCtion of perfons dead 
of peripneumony, the external membrane of 
the lungs, or fome part of the pleura, has ap- 
peared to have been confiderably affected. 

CCCXLIII. 

An inflammation of the pleura covering the 
upper furface of the diaphragm, has been dif- 
tinguifhed by the appellation of Paraphreni- 
as, as fuppofed to be attended with the pecu- 
liar fymptoms of delirium, rifus fardonicus, 
and other convul five motions ; but it is certain, 
that an inflammation of that portion of the 

pleura, 



OF PHYSIC. 245 

pleura, and affe&ing alfo even the mufcular 
fubftance of the diaphragm,has often taken place 
without any of thefe fymptoms ; and I have 
not met with either diifettions, or any ac- 
counts of diffeclions, which fupport the opin- 
ion, that an inflammation of the pleura cover- 
ing the diaphragm, is attended with delirium 
more commonly than any other pneumonic 
inflammation. 

CCCXLIV. 

With refpect to the feat of pneumonic in- 
flammation, I muft obferve further, that al- 
though it may arife and fubfift chiefly in one 
part of the pleura only, it is however frequent- 
ly communicated to other parts of the fame, 
and. commonly communicates a morbid affec- 
tion through its whole extent. 

CCCXLV. 

The remote caufe of pneumonic inflamma- 
tion, is, commonly, cold applied to the body, 
obftru&ing perfpiration, and determining to 
the lungs j while at the fame time the lungs 
themfelvea are expofed to the action of cold. 
Thefe circumftances operate especially, when 
an inflammatory diathefis prevails in the fyf- 
tem ; and confequently, upon perfons of the 
greateft vigour ; in cold climates ; in the win- 
ter feafon ; and particularly in the fpring, 
when viciflitudes of heat and cold are fre- 
L 3 qucnt. 



246 PRACTICE 

quent. The difeafe, however, may arife in any 
ieafon when fuch viciflitudes occur. 

Other remote caufes alfo may have a fhare 
in this matter ; fuch as every means of ob- 
ftructing, flraining, or otherwife injuring, the 
pneumonic organs. 

Pneumonic inflammation may happen to 
perfons of any age, but rarely to thofe under 
the age of puberty ; and moft commonly it 
affe6te perfons fomewhat advanced in life, as 
thofe between forty five and fixty years ; thofe, 
too, efpecially of a robuft and full habit. 

The pneumonic inflammation has been 
fometimes fo much an epidemic, as to occa- 
fion a fufpicion of its depending upon a fpe- 
cific contagion ; but I have not met with any 
evidence in proof of this. See Morgagni 
de caufis etfedibus morlorum, epifl. xxi. art. 26. 

CCCXLVI. 

The pneumonic, like other inflammations, 
may terminate by refolution, fuppuration, or 
gangrene ; but it has alfo a termination pecu- 
liar to itfelf, as has been hinted above, 
(CCLIX) ; and that is, when it is attended 
with an effufion of blood into the cellular 
texture of the lungs, which foon interrupting 
the circulation of the blood through this vif- 
cus, produces a fatal fuffocation. This, in- 
deed, feems to be the moft common termina- 
tion of pneumonic inflammation, when it ends 

fatally ; 



OF PHYSIC. 247 

fatally ; for, upon the diffe&ion of almoft ev- 
ery perfon dead of the difeafe, it has appeared 
that fuch an effufion had happened. 

CCCXLVII. 

From thefe diffe&ions alfo we learn, that 
pneumonic inflammation commonly produces 
an exudation from the internal furface of the 
pleura ; which appears partly as a foft vifcid 
cruft, often of a compact, membranous form, 
covering every where the furface of the pleu- 
ra, and particularly thofe parts where the 
lungs adhere to the pleura coftalis, or mediaf- 
tinum ; and this cruft feems always to be the 
cement of fuch adhe lions. 

The fame exudation fhows itfelf, alfo, by a 
quantity of a ferous whitifh fluid, commonly 
found in the cavity of the thorax ; and fome 
exudation or effufion is ufually found to have 
been made likewife into the cavity of the pe- 
ricardium. 

CCCXLVIII. 

It feems probable, too, that a like effufion 
is fomctimes made into the cavity of the 
bronchiae ; for, in fome perfons who have di- 
ed after labouring under a pneumonic inflam- 
mation for a few days only, the bronchiae have 
been found filled with a confiderable quantity 
of a ferous and thickifti fluid ; which, I think, 
inuft be confidered rather as the effufion raen- 
L 4 tioned, 



248 PRACTICE 

tioned, having had its thinner parts talccn off 
by refpiration, than as a pus fo fuddenly 
formed in the inllamed part. 

CCCXLIX. 

It is, however, not improbable, that this 
effufion, as well as t-hat made into the cavi- 
ties of the thorax and pericardium, may be a 
matter of the fame kind with that which, in 
other inflammations, is poured into the cellu- 
lar texture of the parts inflamed, and there 
converted into pus ; but, in the thorax and 
pericardium, it does not always aflume that 
appearance, becaufe the craft covering the 
furface prevents the abforption of the thinner 
part. This abforption, however, may be 
compenfated in the bronchiae by the drying 
power of the air ; and therefore the effufion 
into them may put on a more purulent ap- 
pearance. 

In many cafes of pneumonic inflammation, 
when the Sputa are very copious, it is diffi- 
cult to fuppofe that the whole of them pro- 
ceed from the mucous follicles of the bron- 
chiae. It feems more probable that a great 
part of them may proceed from the effufed fe- 
rous fluid we have been mentioning ; and this 
too will account for the fputa being fo often 
of a purulent appearance. Perhaps the fame 
thing may account for that purulent expecto- 
ration, as well as that purulent matter found 
in the bronchiae, which the learned Mr. de 

Haen 



OF PHYSIC. 240 

Haen fays he had often obfervcd, when there 
was no ulceration of the lungs ; and th 
planation, is at lead more probable, than Mr. 
de Hacn's fuppofition of a pus formed in the 
circulating blood, 

CCCL. 

To conclude this fubject, it would appear,,, 
that the efFufion into the bronchia?, which we 
have mentioned, often concurs with the efFu- 
fion of red blood in occafioning the fuffoca- 
tion, which fatally terminates pneumonic in- 
flammation ; that the efFufion of ferum alone 
may have this effect; and, that the ierum 
poured out in a certain quantity, rather than 
any debility in the powers of expectoration, is 
the caufe of that ceafing of expectoration 
which very conftantly precedes the fatal event. 
For, in many cafes, the expectoration has 
ceafed, when no other fymptoms of debility 
have appeared, and when, upon di flection, the 
bronchiae have been found full of liquid mat- 
ter. Nay, it is even probable, that, infome- 
cafes, fuch an efFufion may take place, with- 
out any fymptoms of violent inflammation ;. 
and, in other cafes, the efFufion taking place, 
may feem to remove the fymptoms of inflam- 
mation which had appeared before, and thus 
account for thofc unexpected fatal termina- 
tions which have fometimes happened. Pof- 
fibly this efFufion may account alio lor many of 
the phenomena of the Peripneumonia Noth.i,. 
L 5 CCCLL 



250 PRACTICE 

CCCLI. 

Pneumonic inflammation feldom terminates 
by resolution, without being attended with 
me evident evacuation. An hemorrhagy 
from the nofe happening upon fome of the 
iirft days of the diieafe, has Sometimes put an 
end to it ; and it is Said, that an evacuation 
from the hemorrhoidal veins, a bilious evac- 
uation by (tool, and an evacuation of urine 
with a copious Sediment, have feverally had 
the fame effect. ; but fuch occurrences have 
been rare and unufual. 

The evacuation moll frequently attending, 
and feeming to have the greate ft effect in pro- 
moting resolution, is an expectoration of a 
thick white or yellowifh matter, a little ftreak- 
ed with blood, copious, and brought up 
without either much or violent coughing. 

Very frequently the resolution of this dif- 
eafe is attended with, and perhaps produced 
by y a fweat, which is warm, fluid, copious 
over the whole body, and attended with an 
abatement of the frequency of the pulfe, of 
the heat of the body, and of other febrile 
Symptoms^ 

CCCLII. 

The prognostics in this difeafe are formed 
from obServing the ftate of the principal 

fymp^Sms. 

V violent pyrexia is always dangerous. 

The 



© F F" tt ■ Y b I C. 251 

The danger, however,, is chiefly denoted by 
the difficulty of breathing. When the patient 
can lie on one fide only ; when he can lie ori 
neither fide, but upon his back only ; when 
he cannot breathe with tolerable eafe, except, 
the trunk of his body be ere£t ; when, even 
in this pofture, the breathing is very difficult, 
and attended with a turgefcene and flufhing 
of the face, together with partial fweats about 
the head and neck, and an irregular pulfe ; 
thefe circumftances mark the difficulty of 
breathing in progreffive degrees, and, confe- 
quently, in proportion, the danger of the 
difeafe. 

A frequent violent cough aggravating the 
pain, is always the fymptom of an obftinate 
difeafe. 

As I apprehend that the difeafe is hardly 
ever refolved, without fome expectoration; 
fo a dry cough mufl be always an unfavourable 
fymptom. 

As the expectoration formerly defcribed, 
marks that the difeafe is proceeding to a ref- 
olution ; fo an expectoration which has not 
the conditions there mentioned, mud denote 
at leaft a doubtful ftate of the difeafe ; but 
the marks taken from the colour of the matter, 
are for the mofl part fallacious. 

An acute pain, very much interrupting in— 
fpiration, is always the mark of a violent dif- 
eafe ; though not of one more dangerous, than 
an obtufe pain, attended with very difficult 
refpiration. 

L 6 When: 



252 practice 

When the pains, which at firfl had affecTed 
one fide only, have afterwards fpread into the 
other ; or when, leaving the fide firll affected, 
they entirely pafs into the other ; thefe are 
always marks of an increafing, and therefore 
of a dangerous, difeafe. 

A delirium coming on during a pneumonic 
inflammation, is conflantly a fymptom de- 
noting much danger. 

CCCLIII. 

When the termination of this difeafe proves 
fatal,, it is on one or other of the days of the 
firfl week, from the third to the feventh. This 
is the moil common cafe ; but in a few inflan- 
ces, death has happened at a later period of 
rhe difeafe,. 

When the difeafe is violent, but admitting 
of refolution, this alfo happens frequently in 
the courfe of the firfl week ; but, in a more 
moderate flate of the difeafe, the refolution is 
often delayed to the fecond week. 

The difeafe, on fome of the days from the 
third to the feventh, generally differs a re- 
mifTion ; which, however, may be often falla- 
cious, as the difeafe does fometimes return 
again with as much violence as before, and 
then with great danger. 

Sometimes the difeafe difappears on the 
fccond or third day, while an eryfipelas makes 
its appearance on fome external part y and, if 

this 



OF PHYSIC. 253 

this continue fixed, the pneumonic inflam- 
mation does not recur. 

CCCLIV. 

Pneumonia, like other inflammations, often 
ends in fuppuration or gangrene. 

CCCLV. 

When a pneumonia, with fymptoms neither 
very violent nor very flight, has continued 
for many days, it is to be feared it will end in 
a fuppuration. This, however, is not to be 
determined precifely by the number of days j 
for, not only after the fourth, but even after 
the tenth day, there have been examples of 
a pneumonia ending by a refolution ; and if 
the difeafe has fuffered lome intermrffion, and 
again recurred, there may be inftances of a 
refolution happening at a much later period 
from the beginning of the difeafe, than that 
jufl now mentioned. 

CCCLVI. 

But if a moderate difeafe, in fpite of proper 
remedies employed, be protra&ed to the four- 
teenth day without any confiderable remiflion, 
a fuppuration is pretty certainly to be expect- 
ed ; and it will be Itill more certain, if no 
figns of refolution have appeared, or if an ex- 
pecloration, which had appeared (hail have 

again 



254 PRACTICE 

again ceafed, and the difficulty of breathing 
has continued or increafed, while the other 
fymptoms have rather abated. 

CCCLVII. 

That, in a pneumonia, the effufion is made, 
which may lay the foundation of a' i'uppu- 
ration, we conclude from the difficulty of 
breathing becoming greater when the patient 
is in a horizontal pofture, or when he can 
lie more eafily upon the afFecled fide. 

CCCL.VIH. 

That, in fuch cafes, a fuppuration 
actually begun, may be concluded from the 
patient's being frequently affe&ed with flight 
cold fhiverings, and with a fenfe of cold felt 
fometimes in one and fometimes in another 
part of the body. We form the fame con- 
clufion alfo from the ftate of the pulfe, which 
is commonly lefs frequent and fofter, but fome- 
times quicker and fuller, than before, 

CCCLIX. 

That a fuppuration is already formed, may 
be inferred from there being - a confiderabie 
remiffion of the pain which had before fub- 
fifled, while, along with this, the cough, and 
efpecially the dyfpncea, continue, and are 
rather augmented. At the fame time, the fre- 
quency 



O F P H Y S I C. 25$ 

quency of the pulfe is rather increafed ; the 
feverifh ftate fufFers confiderable exacerbations 
every evening, and by degrees a he6lic in all 
its circumftances comes to be formed. 

CCCLX. 

The termination of Pneumonia by gangrene, 
is much more rare than has been imagined ; 
and, when it does occur, it is ufually 
joined with the termination by effufion 
(CCCXLVI), and the fymptoms of the one 
are hardly to be diftinguiflied from thofe of 
the other. 

CCCLXI. 

The (pure of pneumonic inflammation muft 
proceed upon the general plan (CCLXIV); 
but the importance of the part affected and 
the danger to which it is expofed, require 
that the remedies be fully, as well as early, 
employed. 

CCCLXII. 

The remedy chiefly to be depended upon, 
is that of bleeding at the arm ; which will be 
performed with mod advantage in the arm of 
the fide affected ; but may be done in either 
arm, as may be moft convenient for the patient 
or the furgeon. The quantity drawn mufl 
be fuited to the violence of the difeafe, and to 

the 



256 P R A C T I C 

the vigour of the patient ; and generally ought 
to be as large as this laftcircumflance wilt allow. 
The remiflion of pain, and the relief of ref- 
piration during the flowing of the blood, may 
limit the quantity to be then drawn ; but if 
thefe fymptoms of relief do not appear, the 
bleeding mould be continued till the fymp- 
toms of a beginning fyncope come on. It is 
feldom that one bleeding, however large, will 
prove a cure of this difeafe ; and although the 
pain and difficulty of breathing may be much 
relieved by the firil bleeding, thefe fymptoms 
commonly, and after no long interval, recur; 
often with as much violence as before. In the 
event of fuch recurrence, the bleeding is to 
be repeated, even in the courfe of the fame 
day, and perhaps to the fame quantity as before. . 
Sometimes the fecond bleeding may be 
larger than the firfl. There are perfons who, 
by their conflitution, are ready to faint even 
upon a fmall bleeding j and, in fuch perfons, . 
this may prevent the drawing fo much blood 
at firfl as a pneumonic inflammation might re- 
quire ; but, as the fame perfons are frequent- 
ly found to bear after bleedings better than the 
firfl, this allows the fecond and fubfequent 
bleedings to be larger, and to fuch a quantity 
as the fymptoms of the difeafe may fecm 
demand. 

GCCLXIII. 

It is according to the flate of the fymptoms 
that bleedings are to be repeated ; and they 

will 



OF PHYSIC. 257 

will be more efFe&ual when praclifcd in the 
courfe of the firfl three days, than afterwards ; 
but they are not to be omitted, although four 
days of the difeafe may have already elapfed. 
If the phyfician fhall not have been called in 
fooner ; or if the bleedings pracliled during 
the firfl days fhall not have been large enough, 
or even although thefe bleedings fhall have 
procured fome remiflion ; yet, upon the re- 
currence of the urgent fymptoms, the bleeding 
fhould be repeated at any period of the dii- 
eafe, efpecially within the firfl fortnight ; and 
even afterwards, if a tendency to fuppuration 
be not evident, or if, after a feeming folution, 
the difeafe fhall have again returned. 

CCCLXIV. 

With refpefl to the quantity of blood which 
ought, or which with fafety may be taken 
away, no general rules can be delivered, as 
it mufl be very different, according to the 
flate of the difeafe, and the conftitution of the 
patient. In an adult male of tolerable 
flrength, a pound of blood, avoirdupois, is 
a full bleeding. Any quantity above twenty 
ounces is a large, and any quantity below 
twelve a fmall, bleeding. A quantity of from 
four to five pounds, in the courfe of two 01 
three days, is generally as much as fuch 
patients will fafely bear ; but, if the intervals 
between the bleedings and the whole of the 
time during which the bleedings have been 

employed 



258 PRACTICE 

employed have been long, the quantity taken 
upon the whole may be greater. 

CCCLXV. 

When a large quantity of blood has been 
already taken from the arm, and when it is 
doubtful if more can with fafety be drawn in 
that manner, fome blood may flill be taken 
by cupping and fcarifying. Such a meafure 
will be more particularly proper, when the 
contiuance or recurrence of pain, rather than 
the difficulty of breathing, becomes the urgent 
fymptom ; and then the cupping and fcar- 
ifying mould be made as near to the pained 
part as can conveniently be done. 

CCCLXVI. 

An expectoration takes place fometimes 
very early in this difeafe ; but if, notwith- 
flanding that, the urgent fymptoms fhould 
flill continue, the expectoration mud not 
fuperfede the bleedings mentioned ; and 
during the firft days of the difeafe, its folution 
is not to be trufted to the expectoration alone. 
It is in a more advanced ftage only, when the 
proper remedies have been before employed, 
and when the fymptoms have fuffered a con- 
fiderable remiffion, that the entire cure may 
be trufted to a copious and free expectoration. 

CCCLXVII. 



OF PHYSIC. 259 



CCCLXVII. 

During the firft days of the difeafe, I have 
not found that bleeding flops expectoration. 
On the contrary, I have often obferved bleed- 
ing promote it; and it is in a more advanced 
ftage of the difeafe only, when the patient, by 
large evacuations, and the continuance of the 
difeafe, has been already exhaufted, that 
bleeding feems to flop expectoration. It 
appears to me, that even then bleeding does 
not flop expectoration fo much by weakening 
the powers of expectoration, as by fa- 
vouring the ferous effufion into the bronchi ae 
(CCCXLVIII), and thereby preventing it. 

CCCLXVIII. 

While the bleedings we have mentioned mail 
be employed, it will be neceflary to employ 
alfo every part of the antiphlogiftic regimen 
(CXXX- CXXXII), and particularly to 
prevent the irritation which might arife from 
any increafe of heat. For this purpofe, it 
will be proper to keep the patient out of bed, 
while he can bear it eafily j and, when he 
cannot, to cover him very lightly while he 
lies in bed. The temperature of his chamber 
ought not to exceed fixty degrees of Faren- 
heit's thermometer; and whether it may be 
at any time colder, I am uncertain. 

CCCLXIX. 



a6o PRACTICE 

CCCLXIX. 

Mild and diluent drinks, moderately tepid,, 
at leaft never cold, given by lrnall portions at 
a time, ought to be adminiftered plentifully. 
Thefe drinks may be impregnated with vegeta- 
ble acids. They may be properly accompanied 
alio with nitre, or fome other neutrals; but thefe 
lalts mould be given feparately from the drink. 

It has been alleged, that both acids 
nitre are ready to excite coughing, and in 
perfons they certainly have this effect ; but,, 
except in perfons of a peculiar habit, I have 
not found their effects in exciting cough fo 
confiderable or troublefome as to prevent our 
feeking the advantages otherwife to be obtain- 
ed from thefe medicines. 

CCCLXX. 

Some practitioners have doubted, if purga- 
tives can be fafely employed in this difeafe ; 
and indeed a fpontaneous diarrhoea occurring 
in the beginning of the difeafe has feldom 
proved ufeful ; but I have found the mode- 
rate ufe of cooling laxatives generally fafe ; and 
have always found it ufeful to keep the belly 
open by frequent emollient glyflers. 

CCCLXXI. 

To excite full vomiting by emetics, I judge 
to be a dangerous practice in this difeafe j but 

I 



OF PHYSIC. 261 

I have found it ufeful to exhibit naufeating 
doles ; and, in a fomewhat advanced ftate of 
the difeafe, I have found fuch dofes prove the 
belt means of promoting expectoration. 

CCCLXXII. 

Fomentations and poultices applied to the 
pained part have been recommended, and may 
be ufeful ; but the application of them is oft- 
en inconvenient, and may be entirely omitted 
for the fake of the more effecliual remedy,, 
bliflering. 

Very early in the difeafe, a blifler mould 
be applied as near to the pained part as poffi- 
ble. But as, when the irritation of a blifler 
is prefent, it renders bleeding lefs effectual ; fo 
the application of the Milter mould be delayed 
till a bleeding fhall have been employed. If 
the difeafe be moderate, the blifter may be 
applied immediately after the firfl bleeding ; 
but if the difeafe be violent, and it is prefum- 
ed that a fecond bleeding may be neceflary 
foon after the firft, it will then be proper to 
delay the blifter till after the fecond bleeding, 
when it may be fuppofed that any farther 
bleeding may be poftponed till the irritation 
arifing from the blifter (hall have ceafed. It 
may be frequently neceflary in this difeafe to 
repeat the bliftering ; and, in that cafe, the 
pi afters fliould always be applied fomewhere 
on the thorax ; for, when applied to more dif- 
tant parts, they have little effect. The keeping 

the 



2 62 PRACTICE 

the bliflered parts open, and making what is 
called a perpetual blifter, has much lefs effeft 
than a frefh bliftering. 

CCCLXXIII. 

As this difeafe often terminates by an ex- 
pectoration, fo various means of promoting 
this have been propofed ; but none of them 
appear to be very effectual ; and fome of them, 
being acrid ftimulant fubftances, cannot be 
very fafe. 

The gums ufually employed feem too 
heating ; fquills feem to be lefs fo ; but they 
are not very powerful, and fometimes incon- 
venient by the conftant naufea they induce. 

The volatile alkali may be of fervice as an 
expectorant ; but it mould be referved for an 
advanced ftate of the difeafe. 

Mucilaginous and oily demulcents appear 
to be ufeful, by allaying that acrimony of the 
mucus which occafions too frequent cough- 
ing ; and which coughing prevents the ft agna- 
tion and thickening of the mucus, and thereby 
its becoming mild. 

The receiving into the lungs the fleams of 
warm water impregnated with vinegar, has 
often proved ufeful in promoting expectora- 
tion. 

But, of all other remedies, the mod power- 
ful for this purpofe, are antimonial medicines, 
e;iven in naufeating dofes, as in CLXXIX. 
(Of thefe, however, I have not found the 

kermcs 



O F P H Y S I C. 263 

kermes mineral more efficacious than emetic 
tartar, or antimonial wine ; and the dofe of the 
kermes is much more uncertain than that of 
the others. 

CCCLXXIV. 

Though a fpontaneous fweating often 
proves the crifis of this difeafe, it ought not 
to be excited by art, unlefs with much cau- 
tion. At leaft, I have not yet found it either 
fo effectual or fafe, as fome writers have alleg- 
ed. When, after fome remiflion of the fymp- 
toms, fpontaneous fweats of a proper kind a- 
rife, they may be encouraged ; but it ought to 
be without much heat, and without ftimulant 
medicines. If, however, the fweats be partial 
and clammy only, and a great difficulty of 
breathing ftill remain, it will be very danger- 
ous to encourage them. 

CCCLXXV. 

Phyficians have differed much in opinion 
with regard to the ufe of opiates in pneumon- 
ic inflammation. To me it appears, that, in 
the beginning of the difeafe, and before bleed- 
ing and bliftering have produced fome remiflion 
of the pain, and of the difficulty of breathing, 
opiates have a very bad effe£t, by their in- 
creafing the difficulty of breathing, and other 
inflammatory fymptoms. But in a more ad- 
vanced ftate of the difeafe, when the difficulty 

of 



264 PRACTICE 

of breathing has abated, and when the urgent 
fymptom is a cough, proving the chief cauie of 
the continuance of the pain and of the want 
of fleep, opiates may be employed with great 
advantage and fafety. The interruption of the 
expectoration, which they feem to occafion, is 
for a fhort time only ; and they feem often to 
promote it, as they occafion a ftagnation of 
what was by frequent coughing diflipated in- 
fenfibly, and therefore give the appearance of 
what phyficians have called Concocted Mat- 
ter. 



CHAP. 



OF PHYSIC. 265 



C PI A P. VII. 



of the PERIPNEUMONIA NOTHA, 
oa BASTARD PERIPNEUMONY. 



CCCLXXVI.. 



;name 



A DISEASE under this l_ 
is mentioned in fome medical writings of the 
fixteenth century ; but it is very doubtful if 
the name was then applied to the fame difeafe 
to which we now apply it. It appears to me, 
that unlefs fome of the cafes defcribed under 
the title of Catarrhus SufFocativus be fuppof- 
ed to have been of the kind I am now to treat 
of, there was no defcription of this difeafe giv- 
en before that by Sydenham, under the title I 
have employed here. 

CCCLXXVII. 

After Sydenham, Boerhaave was the full 
who in a fyftem took notice of it as a diftin6l 
difeafe ; and he has defcribed it in his aphor- 
ifms, although with fome circumflances differ- 
ent from thofe in the defcription of Sydenham. 
Of late, Mr. Lieutaud has with great confi- 
dence afferted, that Sydenham and Boerhaave 
M • had, 



2 66 PRACTICE 

had, under ihc fame title, defcribed different 
difeafes ; and that, perhaps, neither of them 
had on this fubjefct delivered any thing but 
hypothecs. 

CCCLXXVIII. 

Notwithftanding this bold affertion, I am 
humbly of opinion, and the Baron Van 
Swieten feems to have been of the fame, that 
Sydenham and Boerhaave did defcribe under 
the fame title, one and the fame difeafe. Nay, 
I am further of opinion, that the difeafe de- 
fcribed by Mr. Lieutaud himfelf, is not effen- 
tially different from that defcribed by both the 
other authors. Nor will the doubts of the very 
learned, but modeft Morgagni, on this fubjeft, 
diflurb us, if we confider, that while very few 
defcribers of difeafes either have it in their 
power, or have been fufliciently attentive in 
diflinguifhing between the efTential and acci- 
dental fymptoms of difeafe ; fo, in a difeafe 
which may have not only different, but a 
greater number of fymptoms, in one perfon 
than it has in another, we need not wonder 
that the defcriptions of the fame difeafe by 
different perfons fhould come out in fome re- 
fpetts different. I mall, however, enter no 
further into this controverfy ; but endeavour 
to defcribe the difeafe as it has appeared to 
myfelf ; and, as I judge, in the effential fymp- 
toms, much the fame as it has appeared to all 
the other authors mentioned. 

CCCLXXIX. 



OF PHYSIC. 267 



CCCLXXIX. 

This difeafe appears at the lame feafon-; 
that other pneumonic and catarrhal affections 
< ommonlydo; that is, in autumn and in fpring. 
Like thefe difeafcs, alfo, it is feemingly occa- 
fioned by fudden changes of the weather from 
heat to cold. It appears, alfo, during the prev- 
alence of contagious catarrhs ; and it is fre- 
quently under the form of the Peripneumonia 
Notha, that thefe catarrhs prove fatal to elder- 
ly perfons. 

This difeafe attacks mofl commonly per- 
fons fomewhat advanced in life, efpecially 
thofe of a full phlegmatic habit ; thofe who 
have before been frequently liable to catarrhal 
affections, and thofe who have been much ad- 
dicted to the large ufe of fermented and fpir- 
ituous liquors. 

The difeafe commonly comes on with the 
fame lymptoms as other febrile difeafes ; that 
is, with alternate chills and heats ; and the 
fymptoms of pyrexia are fometimes fufficiently 
evident ; but in moft cafes thefe are very 
moderate, and in fome hardly at all appear. 
With the fifft attack of the difeafe, a cough 
xomes on ; ufually accompanied with fome 
expectoration ; and in many cafes there is a 
frequent throwing up of a confiderable quan- 
tity ot a vifcid opaque mucus. The cough 
often becomes frequent and violent ; is fome-' 
Minos accompanied with a rending headach ; 
M 2 an.!. 



268 PRACTICE 

and, as in other cafes of cough, a vomiting is 
fometimes excited by it. The face is lome- 
times flufhed, and fome giddinefs or drow fi- 
nds often attends the difeafe. A difficvilty 
of breathing, with a fenfe of oppreifion, or 
fhaitening in the cheft, with fome obfeure 
pains there, and a fenfe of laflitude over the 
whole body, very conftantly attend this dif- 
eafe. The blood drawn in this difeafe, fhows 
a huffy furface, as in other inflammatory af* 
fections. 

The difeafe has often the appearance only 
of a more violent catarrh, and after the em- 
ployment of fome remedies is entirely relieved 
by a free and copious expectoration. In oth- 
er cafes, however, the feverifh and catarrhal 
fymptoms are at firfl very moderate, and even 
flight ; but, after a few days, thefe fymptoms 
fuddenlv become confiderable, and put an end 
to the patient's life when the indications of 
danger were before very little evident. 

CCCLXXX. 

From the different circumflances in which 
this difeafe appears, the pathology of it i^ dif- 
ficult. It is certainly often no other at firfl than 
a catarrhal affection, which, in elderly perfons, 
is frequently attended with a large afflux of 
mucus to the lungs ; and it was on this foot- 
ing that Sydenham confidered it as only dif- 
fering in degree from his Feb r is Hyemalis. 
A catarrh, however, is ftri&ly an affection of 

the 



OF PHYSIC. 269 

the mucous membrane and follicles of the 
bronchiae alone ; but it may readily have, and 
frequently has, a degree of pneumonic inflam- 
mation joined to it ; and in that cafe may 
prove more properly the peculiar difeafe we 
treat of here. But, further, as pneumonic in- 
flammation very often produces an effufion 
offerum into the bronchiae (CCCXLVIII), 
fo this, in elderly perfons, may occur in con- 
fluence of a flight degree of inflammation ; 
and when it does happen, will give the exqui- 
fite and fatal cafes of the peripneumonia notha. 



CCCLXXXI. 



After this attempt to eftabliih the patholo- 
gy, the method of cure in the different cir- 
cumftances of the difeafe will not be difficult. 

In cafe the fever, catarrhal and pneumonic 
fymptoms, are immediately confiderable, a 
bloodletting will certainly be proper and nec- 
effary ; but, where thefe fymptoms are mode- 
rate, a bloodletting will hardly be requifite ; 
and, when an effufion is to be feared, the repl 
etition of bloodletting may prove extremely 
hurtful. 

In all cafes, the remedies chiefly to be de- 
pended upon, are vomiting and Wittering. 

Full vomiting may be frequently repeated, 
and naufeating dofes ought to be conflantly 
employed. 

M 3 Purging 



2 7 o PRACTICE 

Purging may perhaps be ufeful ; but 
is feldom To in pneumonic affections, nothing 
but gentle laxatives arc here neceifary. 

In all the circumf lances of this difeafe, the 
antiphlogiftic regimen is proper ; cold is to be 
guarded againft ; but much external heat is 
carefully avoided. 

CCCLXXXIL 



it a perfon iweats eafily, and it can be 
brought out by the ufe of mild tepid liquors 
only, the practice may in fuch perfons be tri- 
ed. See Morgagni Dt Sed. et Cauf. Epift. 
xiii. Art. 4. 



CCCLXXXIII. 

I might here, perhaps, give a feparate fe&ion 
on the Carditis and Pericarditis, or the In- 
flammations of the Heart and Pericardium ; 
but they hardly require a particular confid- 
eration. An acute inflammation of the peri- 
cardium is almoft always a part of the fame 
pneumonic affection I have been treating of ; 
and is not always diflinguifhed by any differ- 
ent fymptoms ; or, if it be, does not require 
any different treatment. The fame may be 
faid of an acute inflammation of the heart it- 
felf ; and when it happens that the one or oth- 
er is discovered by the fymptoms of palpita- 
tion or fyncope, no more will be implied than 

that 



OF PHYSIC. 271 

» 

that the remedies of pneumonic inflammation 
mould be employed with greater diligence. 

From difle&ions, which fhow the heart and 
pericardium affe&ed with erolions, ulcerations, 
and abfcefles, we difcover, that thefe parts had 
been before affected with inflammation ; and 
that in cafes where no fymptoms of pneumon- 
ic inflammation had appeared ; it may there- 
fore be alleged, that thofe inflammations of 
the heart and pericardium fhould beconfider-/ 
ed as difeafes independent of the pneumonic. 
This indeed is juft ; but the hiftory of fuch 
cafes proves, that thofe inflammations had 
been of a chronic kind, and hardly discovering 
themfelves by any peculiar fymptoms ; or, if 
attended with fymptoms marking an affection 
of the heart, thefe were, however, fuch as have 
been known frequently to arife from other 
caufes than inflammation. There is, there- 
fore, upon the whole, no room for our treat- 
ing more particularly of the inflammation of 
the heart or pericardium. 



M 4 CHAP. 



272 PRACTICE 



CHAP. VIII. 



of the GASTRITIS, or INFLAMMA- 
TION of the STOMACH. 



CCCLXXXIV. 

AMONG the inflammations 
of the abdominal region, I have given a place 
in our Nofology to the Peritonitis ; compre- 
hending under that title, not only the inflam- 
mations affecting the peritonaeum lining the 
cavity of the abdomen, but alfo thofe affecting 
the extenfions of this membrane in the 
omentum and mefentery. It is not, however, 
propofed to treat of them here, becaufe it is 
very difficult to fay by what fymptoms they are 
always to be known ; and farther, becaufe, 
when known, they do not require any reme- 
dies befide thofe of inflammation in general. 
I proceed, therefore, to treat of thofe inflam- 
mations, which, affecting vifcera of peculiar 
functions, both give occafion to peculiar fymp- 
toms, and require fome peculiarities in the 
method of cure ; and I fhall begin with the 
inflammation of the ftomach. 

CCCLXXXV. 



OF PHYSIC. 273, 



CCCLXXXV, 

The inflammation of the ftomach is of 
two kinds ; Phlegmonic, or Erythematic*. 
The firft may be feated in what is called the 
Nervous Coat of the ftomach, or in the peri- 
tonaeum invefling. it, The iecond is always 
feated in the villous coat and cellular texture 
immediately fubjacent. 

CCCLXXXVI. 

The Phlegmonic inflammation of the ftom- 
ach, or what has been commonly treated of 
under the title of Gaftritis, is known by an 
acute pain in fome part of the region of the 
ftomach, attended with pyrexia, with frequent 
vomiting, efpecially upon occafion of any 
thing being taken down into the ftomach, and 
frequently with hickup. The pulfe is com- 
monly fmall and hard ; and there is a greater 
lofs of ftrength in all the functions of the 
body, than in the cafe of almoft any other in- 
flammation. 

CCCLXXXVIL 

This inflammation may be produced by va- 
rious caufes ; as, by external contuiion ; by 
M 5 acrids 

* This is a new term; but whoever confiders what is 
ftid in CCLXXIV, will, I expert, perceive the proprie* 
:y-i\nd even the nece-flity, of it. 



274 PRACTICE 

acrids of various kinds taken into the ftom- 
ach ; frequently by very cold drink, taken in- 
to it, while the body is very warm ; and fome- 
timcs by over diftention, from the having tak- 
en in a large quantity of food of difficult di- 
geftion. All thele may be confidered as ex- 
ternal caufes ; but the diieale foractimes arifes 
alio from internal caufes not fo well under- 
Itood. It may arife from inflammations of 
the neighbouring parts communicated to the 
flomach, and is then to be confidered as a 
fymptomatic affection only. It may arife al- 
io from various acrimonies generated within 
the body, either in the ftomach itfelf, or in 
other parts, and poured into the cavity of the 
ftomach. Thefe are caufes more directly ap- 
plied to the flomach ; but there are perhaps 
others originating elfewhere, and affecting the 
ilomach only fympathetically. Such may be 
fuppofed to have acted in the cafe of putrid 
fevers and exanthematic pyrexia? ; in which, 
upon diifeclion, it has been difcovered that 
the flomach had been affected with inflam- 
mation. 

CCCLXXXVIII. 

From the fenfibility of the flomach, and its 
communication with the reft of the fyftetn, it 
will be obvious, that the inflammation of this 
organ, by whatever caufes produced, may be 
attended with fatal confequences. In partic- 

ar, by the great debility which fuch an in- 
flammation 



OF PHYSIC. 275 

flammation fuddenly produces, it may quickly 
prove fatal, without running the common 
courfe of inflammations. 

When it lafts long enough to follow the or- 
dinary courfe of other inflammations, it may 
terminate by refolution, gangrene, or fuppu- 
ration. The fcirrhofities which are often dis- 
covered affecting the ftomach, are feldom 
known to be the confequences of inflam- 
mation. 

CCCLXXXIX. 

The tendency of this difeafe to admit of 
refolution, may be known by its having arifen 
from no violent caufe j by the moderate flate 
of the fymptoms ; and by a gradual remiffion 
ty^ thefe, especially in confequence of remedies 
employed in the courfe of the firft, or at far^ 
theft the fecond, week of the difeafe. 

cccxc. 

The tendency to fuppuration may be known 
by the fymptoms continuing, in a moderate 
degree, for more than one or two weelts ; and 
Iikewife by a confiderable remitfion of the 
pain, while a fenfe of weight and anxiety ftiH 
remain. 

When an abfeefs has been formed, the fre- 
quency of the pulfc is at full abated ; but foon 
after, it is again increafed, with frequent cold 
ffciverings, and with marked exacerbations in 
M 6 the 



276 PRACTICE 

the afternoon and evening, followed by night 
fweatings and other fymptoms of hettic fever. 
Thefe at length prove fatal, unlefs the abfcefs 
open into the cavity of the ftomach, the pus 
be evacuated by vomiting,, and the ulcer foon 
heal. 

CCCXCI. 

The tendency to gangrene may be fufpe6f- 
ed from the violence of the fymptoms not 
yielding to the remedies employed during the 
fir ft days of the difeafe ; and that a gangrene 
has already begun, may be known from the 
fudden remiflion of the pain, while the fre^ 
queney of the pulfe continues, and at the fame 
time becomes weaker, accompanied with other 
marks of an increafing debility in the whole 
fyitenu 

CCCXCII. 

From the diffection of dead bodies it ap- 
pears,, that the ftomach very often has been 
affected with inflammation, when the charac- 
tenftic fymptoms of it (CCCLXXXVI) had 
not appeared ; and therefore it is very difficult 
to lay down any general rules for the cure of 
this difeafe. 

CCCXCII'I. 

It is only in the cafe of phlegmonic inflam- 
mation, as characlerifed in CCCLXXXVI. 

that 



OF PHYSIC. 277 

that we can advife the cure or refcflution to 
be attempted by large and repeated bleedings 
employed early in the difeafe ; and we are not 
to be deterred from thefe by the fmallnefs of 
the pulfe ; for, after bleeding, it commonly 
becomes fuller and fofter. After bleeding, a 
blifler ought to be applied to the region of the 
ftomach ; and the cure will be aflifted by fo- 
mentations of the whole abdomen, as well as 
by frequent emollient and laxative glyflers. 

CCCXCIV. 

In this difeafe, the irritability of the ftom- 
ach will not admit of any medicines being 
thrown into it ; and, if any internal medicines 
can be fuppofed neceflary, they muft be ex- 
hibited in glyfters. The giving of drink may 
be tried ; but it ought to be of the very mild- 
eft kind, and in very fmall quantities at a time, 

cccxcv. 

Opiates, in whatever manner exhibited, are 
very hurtful during the firft days of the dif- 
eafe ; but when its violence fhall have abated., 
and when the violence of the pain and vomit- 
ing recur at intervals only, opiates given in 
glyfters may be cautioufly tried, and fome- 
times have been employed with advantage. 

CCCXCVL 



2?8 PRACTICE 



CCCXCVI. 

A tendency to fuppuration, in this dif< 
is to be obviated by the means juft now pro- 
pofed. After a certain duration of the dif- 
eafe, it cannot be prevented by any means 
whatever ; and when actually begun, mull be 
left to nature ; the bufmels of the phyfician 
being only to avoid all irritation. 

CCCXCVII. 

A tendency to gangrene can be obviated in 
no other way than by the means iuggefted 
CCCXCIII, employed early in the difeafe ; 
and, when it does actually fupervene, admits 
of no remedy. 

cccxcvrn. 

Erythematic inflammations of the flomach', 
are more frequent than thole of thephlegmon- 
ic kind. It appears, at leafl, from difle&ions, 
that the flomach has often been affected with 
inflammation, when neither pain nor pyrexia 
had before given any notice of it ; and fuch 
inflammation I apprehend to have been chief- 
ly of the erythematic kind. This fpecies of 
inflammation alfo, is efpecially to be expedled 
from acrimony of any kind thrown into the 
flomach ; and would certainly occur more 
frequently from fuch a eaufe, were not tKe 

inte 



OF PHYSIC. 279 

interior furface of this organ commonly de- 
fended by mucus exuding in large quantities 
from the numerous follicles placed immedi- 
ately under the villous coat. Upon many oc- 
cafions, however, the exudation of mueus is 
prevented, or the liquid poured out is of a 
lefs vifcid kind, fo as to be lefs fitted to defend 
the fubjacent nerves ; and it is in fuch cafea 
that matters even of moderate acrimony, may 
produce any erythematic affection of the 
ftomach. 

CCCXCIX. 

From what has been faid it muft appear, 
that an erythematic inflammation of the ftom- 
ach may frequently occur ; but will not al- 
ways difcover itfelf, as it fometimes takes plaoe 
without pyrexia, pain, or vomiting.. 

cccc. 

There are cafes, however, in which it may 
be difcovered. The affection of the ftomach 
fometimes fpreads into the cefophagus, and 
appears in the pharynx, as well as on the 
whole internal furface of the mouth. When, 
therefore, an erythematic inflammation affects 
the mouth and fauces, and when at the fame 
time there {hall be in the ftomach r an unufual 
fenfibility to all acrids, with a frequent vom- 
iting;, there can be little doubt of the ftomach 
being affected with the fame inflammation 

that 



280 PRACTICE 

that has appeared in the fauces. Even when 
no inflammation appears in the fauces, yet if 
fome degree of pain be felt in the ilomach, if 
there be a want of appetite, an anxiety, fre- 
quent vomiting, an unulual knfibility with 
refpec"l to aends, fome thirff, and frequency 
of pulfc, there will then be room to lufpeel 
an erythematic inflammation of the flomach ; 
and we have known fuch fymptoms, after 
fome time, difcover their caufe more clearly 
by the appearance of the inflammation in the 
fauces or mouth. 

Erythematic inflammation is often difpofed 
to fpread from one place to another on the « 
fame furface ; and, in doing fo, to leave the 
place it had at firft occupied. Thus, fuch an 
inflammation has been known to fpread fuc- 
cefBvely along the whole courfe of the ali- 
mentary canal, occafioning in the inteftines 
diarrhoea, and in the flomach vomitings ; the 
diarrhoea ceafing when the vomitings came on, 
or the vomitings upon the coming on of the 
diarrhoea. 

CCCCI. 

When an erythematic inflammation of the 
ftomach fhall be discovered, it is to be treated 
differently, according to the difference of its 
caufes and fymptoms. 

When it is owing to acrid matters taken in 
by the mouth, and when thefe may be fup- 
pofed flill prefent in the flomach, they are to 

be 



OF PHYSIC. 281 

be warned out by throwing in a large quantity 
of warm and mild liquids, and by exciting 
vomiting. At the fame time, if the nature of 
the acrimony and its proper corrector be 
known, this mould be thrown in ; or if a fpe- 
cific corrector be not known, fome general de- 
mulcents mould be employed. 

CCCCII. 

Thefe meafures, however, are more fuited 
to prevent the inflammation, than to cure it 
after it has taken place. When this lafl may 
be fuppofed to be the cafe, if it be attended 
with a fenfe of heat, with pain and pyrexia, 
according to the degree of thefe fymptoms the 
meafures propofed in CCCXCIII, are to be 
more or lefs employed, 

CCCCIII. 

When an erythematic inflammation of the 
ftomach has arifen from internal caufes, if 
pain and pyrexia accompany the difeafe, fome 
bleeding in perfons not otherwife weakened, 
may be employed ; but, as the affection often 
arifes in putrid difeafes, and in convalefcents 
from fever ; fo in thefe cafes, bleeding is in- 
admiflible ; all that can be done being to avoid 
irritation, and to throw into the flomach what 
quantity of acids, and of acefcent aliments, it 
fhall be found to bear. 

In 



282 PRACTICE 

In fome conditions of the body, in which 
this difeafe arifes, the Peruvian bark and bit- 
ters may feem to be indicated ; but an eryth- 
ematic ftate of the ftomach does not comnrn 
ly allow of them. 



C H A P. 



OF PHYSIC. 283 



CHAP. IX. 



of the ENTERITIS, or INFLAMMA- 
TION of the INTESTINES. 



CCCCIV. 

1 HE inflammation of the in- 
teflines, like that of the flomach, may be ei- 
ther phlegmonic, or erythematic ; but, on the 
fubjett of the latter, I have nothing to add to 
what has been faid in the lad chapter ; and 
fhall here therefore treat of the phlegmonic 
inflammation only. 

CCCCVI. 

This inflammation may be known to be 
prefent, by a fixed pain of the abdomen, at- 
tended with pyrexia, coflivenefs, and vomit- 
ing. Practical writers mention the pain in 
this cafe as felt in different parts of the abdo- 
men, according to the different feat of the in- 
flammation ; and fo, indeed, it fometimes 
happens ; but very often the pain fpreads 
over the whole belly, and is felt more efpecial- 
ly about the navel. 

CCCCVII. 



284 PRACTICE 

CCCCVII. 

The Enteritis and Gaftritis arife from like 
caufes ; but the former, more readily than the 
latter, proceeds from cold applied to the low- 
er extremities, or to the belly iticlf. The en- 
teritis has likewife its own peculiar caufes, as 
fupervening upon the ipalmodic colic, incar- 
cerated hernia, and volvulus. 

CCCCVIII. 

Inflammations of the interlines have the 
fame terminations as thofe of the ftomach ; 
and, in both cafes, the feveral tendencies are 
to be difcovered by the fame fymptoms 
(CCCLXXXIX.— CCCXCIJ. 

CCCCIX. 

The cure of the enteritis is, in general, the 
fame with that of the gaftritis (CCCXCIII. & 
feq.) but in the enteritis, there is commonly 
more accefs to the introduction of liquids, of 
acid, acefcent, and other cooling remedies, and 
even of laxatives. As, however, a vomiting 
fo frequently attends this difeafe, care muft be 
taken not to excite that vomiting by either the 
quantity or the quality of any thing thrown 
into the ftomach. 

The fame obfervation, with refpeel: to the 
ufe of opiates, is to be made here as in the 
cafe of gaftritis. 

ccccx. 



OF PHYSIC. 365 



CCCCX. 

Under the title of Enteritis, it has been 
ufual with practical writers to treat of the 
remedies proper for the colic, and its higher 
degree named Ileus ; but, although it be true 
that the enteritis and colic do frequently ac- 
company each other, I ftill hold them to be 
diflincl; difeafes, to be often occurring fepa- 
rately, and accordingly to require and admit 
of different remedies. I mail therefore delay 
i'peaking of the remedies proper for the colic, 
till I fhall come to treat of this difeafe in its 
proper place. 

CCCCXI. 

What might be mentioned with refpecl: to 
the fuppuration or gangrene occurring in the 
enteritis may be Sufficiently underftood from 
what has been faid on the fame fubjecl; with 
refpecl; to the- gaftritis. 



CHAP. 



s86 PRACTICE 



CHAP. X. 



of the HEPATITIS, or INFLAMMA- 
TION OF the LIVER. 



CCCCXII. 

1 HE inflammation of the liv- 
er feems to be of two kinds; the one acute, the 
other chronic. 

CCCCXIII. 

The acute is attended with pungent" pain ; 
confiderable pyrexia ; a frequent, flrong, and 
hard pulfe ; and high coloured urine. 

CCCCXIV. 

The chronic hepatitis very often does not 
exhibit any of thefe fymptoms ; and it is only 
difcovered to have happened, by our finding 
in the liver, upon dilleclion, large abfceiles, 
which are prefumed to be the effecl: of fome 
degree of previous inflammation. As this 
chronic inflammation is feldom to be certain- 
ly known, and therefore does not lead to any 
determined praclice, we omit treating of it 

here, 



OF PHYSIC. 287 

here, and (hall only treat of what relates to 
the acute fpecies of the hepatitis. 

ccccxv. 

The acute hepatitis may be known by a 
pain more or lefs acute in the right hypochon- 
chium, increafed by prefling upon the part. 
The pain is very often in fuch a part of the 
fide as to make it appear like that of a pleuri- 
fy ; and frequently, like that too, is increafed 
on refpiration. The difeafe is, in fome in- 
stances, alfo attended with a cough, which is 
commonly dry, but fometimes humid ; and 
when the pain thus refembles that of a pleuri- 
fy, the patient cannot lie eafily except upon 
the fide affe&ed. 

In every kind of acute hepatitis, the pain is 
often extended to the clavicle, and to the top 
of the moulder. The difeafe is attended fome- 
times with hickup, and fometimes with vom- 
iting. Many practical writers have mention- 
ed the jaundice, or a yellow colour of the fkin 
and eyes t as a very conftant fymptom of the 
hepatitis ; but experience has mown, that it 
may often occur without any fuch fymptom. 

CCCCXVI. 

The remote caufes of hepatitis are not al- 
ways to be difcerned, and many have been af- 
figned on a very uncertain foundation. The 
following feem to be frequently evident. 

1. External 



288 PRACTICE 

l. External violence from contufions or falls, 
and efpecially thofe which have occafioncd a 
fracture of the cranium. 2. Certain paffions 
of the mind. 3. Violent fummer heats. 
4. Violent exercife. 5. Intermittent and re- 
mittent fevers. 6. Cold applied externally, 
or internally ; and therefore in many cafes the 
fame caufes which produce pneumonic in- 
flammation, produce hepatitis ; and whence 
alfo the two difeafes are fometimes joined to- 
gether. 7. Various folid concretions or col- 
lections of liquid matter, in the fubftance of 
the liver, produced by unknown caufes. Laft- 
ly, The acute is often induced by a chronic 
inflammation of this vifcus. 

CCCCXVII. 

It has been fuppofed, that the hepatitis may 
be an affection either of the extremities of the 
hepatic artery, or of thofe of the vena porta- 
rum ; but of the laft fuppofition there is neither 
evidence nor probability. 

CCCCXVIII. 

It feems probable, that the acute hepatitis 
is always an affection of the external mem- 
brane of the liver ; and that the parenchymat- 
ic is of the chronic kind. The acute difeafe 
may be feated either on the convex or on the 
concave furface of the liver. In the former 
cafe, a more pungent pan andhickup may be 

produced, 



OF PHYSIC. 289 

produced, and the refpiration is more confid- 
erably affected. In the latter, there occurs 
lefs pam ; and a vomiting is produced, com- 
monly by Some inflammation communicated 
to the itomach. The inflammation of the 
concave Surface of the liver, may be readily 
communicated to the gall bladder and biliary 
ducts ; and this pei haps is the only cafe of idi- 
opathic hepatitis attended with jaundice, 

CCCCXIX. 

The hepatitis, like other inflammations, may 
end by resolution, Suppuration, or gangrene ; 
and the tendency to the one or the other of 
thefe events, may be known from what has 
been delivered above. 

ccccxx. 

The refolution of hepatitis is often the con- 
fequence of, or is attended with, evacuations 
of different kinds. A hemorrhagy, fometimes 
from the right nollril, and fometimes from the 
hemorrhoidal veffels, gives a Solution of the 
' difeaSe. Sometimes a bilious diarrhoea con- 
tributes to the Same event ; and the reSolution 
of the hepatitis, as of other inflammations, is 
attended with fweating, and with an evacua- 
tion of urine, depofiting a copious Sediment. 
Can this diSeafe be refolved by expectoration ? 
It would Seem to be Sometimes cured by an 
eryfipelas appearing in Some external part. 

N CCCCXXL 



290 PRACTICE 

CCCCXXI. 

When this difeafe has ended in fuppura- 
tion, the pus collected may be difcharged by 
the biliary du&s ; or, if the fuppurated part 
does not any where adhere clofely to the 
neighbouring parts, the pus may be difcharged 
into the cavity of the abdomen ; but if, dur- 
ing the firft (late of inflammation, the af- 
fected part of the liver (hall have formed a clofe 
adhefion to fome of the neighbouring parts, 
the diicharge of the pus after fuppuration 
may be various, according to the different feat 
of the abfcefs. When feated on the convex 
part of the liver, if the adhefion be to the pe- 
ritonaeum lining the common teguments, the 
pus may make its way through thefe, and be 
difcharged outwardly ; or, if the adhefion 
mould have been to the diaphragm, the pus 
may penetrate through this, and into the cav- 
ity of the thorax, or of the lungs ; and through 
the latter may be difcharged by coughing. 
When the abfcefs of the liver is feated on its 
concave part, then, in confequence of adhe- 
fions, the pus may be difcharged into the ftom- 
ach or the inteftincs ; and into thefe laft, ei- 
ther diredly, or by the intervention of the bil- 
iary ducts. 

CCCCXXIL 

The prognoftics in this difeafe are eftablifh- 
ed upon the general principles relating to in- 
flammation, 



OF PHYSIC. 291 

flammation, upon the particular circumftances 
of the liver, and upon the particular Mate of 
its inflammation. 

The cure of this difeafe muft proceed upon 
the general plan ; by bleeding, more or lefs, 
according to the urgency of pain and pyrexia ; 
by the application of blifters ; by fomenta- 
tions, of the external parts in the ufual man- 
ner, and of the internal parts by frequent 
emollient glyfters ; by frequently opening the 
belly by means of gentle laxatives, and by 
diluent and refrigerant remedies. 

CCCCXXIII. 

Although, in many cafes, the chronic hepa- 
titis does not clearly difcover itfelf ; yet, upon 
many occafions, it may perhaps be dif covered, 
or at leaft fufpected, from thofe caufes which 
might affeft the liver (CCCXVI) having 
been applied ; from fome fulnefs and fome 
tenfenefs of weight in the right hypochondri- 
um ; from fome (hooting pains at times felt in 
that region ; from fome uneafmefs or pain felt 
upon prefTure in that part ; from fome unea- 
fmefs from lying upon the left fide ; and laft- 
ly, from fome degree of pyrexia, combined 
with more or fewer of thefe fymptoms. 

When from fome of thefe circumftances a 

chronic inflammation is to be fufpe&ed, it is 

to be treated by the fame remedies as in the 

laft paragraph, employed more or lefs as the 

N 2 deprec 



292 PRACTICE 

degree of the feveral fymptoms (hall more 
diftinctly indicate. 

CCCCXXIV. 

When from either kind of inflammation a 
fuppuration of the liver has been formed, and 
the abfeefs points outwardly, the part mud be 
opened, the pus evacuated, and the ulcer heal- 
ed according to the ordinary rules for cleanf- 
ing and healing fuch abfeefles and ulcers. 

CCCCXXV. 

I might here confider the Splenitis, or in- 
flammation of the fpleen ; but it does not feem 
neceflary, becaufe the difeafe very feldom oc- 
curs. When it does, it may be readily known 
by the character given in our Nofology ; and 
its various termination, as well as the practice 
which it requires, may be underftood from 
what has been already faid with refpeft to the 
inflammations of the other abdominal vifcera. 



CHAP. 



OF PHYSIC. 293 



CHAP. XI. 



o* the NEPHRITIS, or the INFLAM- 
MATION of the KIDNEYS. 



CCCCXXVI. 

1HIS difeafe, like other in- 
ternal inflammations, is always attended with 
pyrexia j and is efpecially known from the re- 
gion of the kidney being affetted by pain, 
commonly obtufe, fometimes pungent. This 
pain is not increafed by the motion of the 
trunk of the body, fo much as a pain of the 
rheumatic kind affecting the fame region. 
The pain of the nephritis may be often dif- 
tinguifhed by its mooting along the courfe of 
the ureter ; and is frequently attended with a 
drawing up of the tefticle, and with a numb- 
nefs of the limb on the fide affecled ; although, 
indeed, thefe fymptonas moft commonly ac- 
company the inflammation arifing from a cal- 
culus in the kidney or in the ureter. The 
nephritis is almoft constantly attended with 
frequent vomiting, and often with coftivenefs 
and colic pains. Ufually the flate of the urine 
is changed ; it is mod commonly of a deep red 
colour, is voided frequently, and in fmall 
N . 3 quantity 



294 PRACTICE 

quantity at a time. In more violent cafes, 
the urine is fometimes colourlefs. 

CCCCXXVII. 

The remote caufes of this difeafe may be 
various ; as, external contufion ; violent or 
long continued riding ; drains of the mufcles 
of the back incumbent on the kidneys ; vari- 
ous acrids in the courfe of the circulation con- 
veyed to the kidney ; and perhaps fome other 
internal caufes not yet well known. The mod 
frequent is that of calculous matter obftrucl- 
ing the tubuli uriniferi, or calculi formed in 
the pelvis of the kidneys, and either (licking 
there, or fallen into the ureter. 

CCCCXXVIIL 

The various event of this difeafe may be 
underftood from what has been delivered on 
the fubjett of other inflammations. 

CCCCXXIX. 

Writers, in treating of the cure of nephri- 
tis have commonly at the fame time treated of 
the cure of the Calculus renalis ; but, though 
this may often produce nephritis, it is to be 
confidered as a diftincl and feparate difeafe ; 
and what I have to ofFer as to the mode of 
treating it, muft be referved to its proper place. 

Here 



OF PHYSIC. 29-0 

Here I (hall treat only of the cure of the 
Nephritis Vera or Idiopathica. 

ccccxxx. 

The cure of this proceeds upon the general 
plan, by bleeding, external fomentation, fre- 
quent emollient glyfters, antiphlogiftic purga- 
tives, and the free ufc of mild and demulcent 
liquids. The application of blifters is hardly 
admiffible ; or, at leaft, will require great care, 
to avoid any confiderable abforption of the 
cantharides. 

CCCCXXXI. 

The Cyftitis, or inflammation of the blad- 
der, is feldom a primary difeafe ; and there- 
fore is not to be treated of here. The treat- 
ment of it, fo far as neceflary to be explained, 
maybe readily underftood from what has been 
already delivered. 

CCCCXXXII. 

Of the vifceral inflammations, there remains 
to be confidered the inflammation of the Ute- 
rus ; but I omit it here, becaufe the confider- 
ation of it cannot be feparatedfrom that of the 
difeafes of child bearing women. 



N 4 CHAP. 



296 PRACTICE 



CHAP. XII. 



of the RHEUMATISM, 



CCCCXXXIII. 

OF this difeafe there are two 
fpecies ; the one named the Acute, the other 
the Chronic rheumatifm. 

CCCCXXXIV. 

It is the Acute Rheumatifm which efpecial- 
ly belongs to this place, as from its caufes, 
fymptoms, and methods of cure, it will appear 
to be a fpecies of phlegmafia or inflammation. 

CCCCXXXV. 

This difeafe is frequent in cold, and more 
uncommon in warm, climates. It appears 
mod frequently in autumn and fpring, lefs 
frequently in winter when the cold is confid- 
erable and conflant, and very feldom during 
the heat of fummer. It may occur, howev- 
er, at any feafon, if viciffitudes of heat and 
cold be for the time frequent. 

CCCCXXXVI- 



<ZT F PHYSIC. 297 



CCCCXXXVI. 

The acute rheumatifm generally ari fes from 
the application of cold to the body when any- 
way unufually warm ; or when one part of the 
body is expofed to cold whilft the other parts 
are kept warm ; or laftly, when the applica- 
tion of the cold is long continued, as it is 
when wet or moift clothes are applied to any 
part of the body. 

ecccxxxvu. 

Thefc caufes may affecl: perfons of all a ores ; 
but the rhucmatifm feldom appears in either 
very young or in elderly perfons, and moft 
commonly occurs from the age of puberty to 
that of thirty five years. 

CCCCXXXVIII. 

Thefe caufes (CCCCXXXVI) may alfo 
affeft perfons of any conftitution ; but they moft 
commonly affecl thofe of a fanguine temper- 
ament. 

CCCCXXXIX. 

This difeafe is particularly diftin^uifhed by. 

pains affeaing the joints,, for "the moft 

part the joints alone, but fometimes affeaing 

alfo the mufcular parts. Very often the pains 

N " 5. fhcQt 



298 PRACTICE 

fhoot along the courfe of the mufcles, from 
one joint to another, and are always much in- 
creafed by the action of the mufcles belonging 
to the joint or joints affected. 

CCCCXL. 

The larger joints are moft frequently af- 
fefled ; fuch as the hip joint, and knees of 
the lower, and the moulders and elbows of the 
upper extremities. The ankles and wrifts are 
alfo frequently affc&ed ; but the fmaller 
joints, fuch as thofe of the toes or fingers, 
feldom fuffer. 

CCCCXLI. 

This difeafe, although fometimes confined to 
one part of the body only, yet very often af- 
fects many parts of it ; and then it comes on 
with a cold ftage, which is immediately fuc- 
ceeded by the other fymptoms of pyrexia, 
and particularly by a frequent, full, and hard 
pulfe. Sometimes the pyrexia is formed be- 
fore any pains are perceived ; but more com- 
monly pains are felt in particular parts, before 
any fymptoms of pyrexia appear. 

CCCCXLII. 

When no pyrexia is prefent, the pain is 
fometimes confined to one joint only ; but, 
when any confiderable pyrexia is prefent, al- 
though 



OF PHYSIC. 299 

though the pain may be chiefly in one joint, 
yet it feldom happens but that the pains aired 
feveral joints often at the very fame time, but 
for the moft part fhifting their place, and, hav- 
ing abated in one joint, become more violent 
in another. They do not commonly remain 
long in the fame joint, but frequently fhift 
from one to another, and fometimes return to 
joints formerly affeaed ; and in this manner 
the difeafe often continues for. a long time. 

CCCCXLIII. 

The pyrexia attending this difeafe has an 
exacerbation every evening, and is moft con- 
fiderable during the night, when the pains al- 
fo become more violent ; and it is at the fame 
time that the pains fhift their place from one 
joint to another. The pains feem to be alfo 
increafed during the night, by the body being 
covered more clofely, and kept warmer. 

CCCCXLIV. 

A joint, after having been for fome time 
afFeaed with pain, commonly becomes af- 
fected alfo with fome rednefs and fwelling, 
which is painful to the touch. It feldom hap- 
pens, that a fwelling coming on does not al- 
leviate the pain of the joint ; but the fwelling 
does not always take off the pain entirelv, nor 
fecure the joint againft.a return of it. 

N 6 CCCCXLV. 



300 PRACTICE, 

CCCCXLV. 

This difeafe is commonly attended with 
fome fweating, which occurs early in the courfe 
of the dileafe ; but it isfeldom free or copious, 
and feldom either relieves the pains or proves 
critical. 

ccccxlvi. 

In the courfe of this difeafe the urine is 
high coloured, and in the beginning without 
fediment ; but as the difeafe advances, and 
the pyrexia has more confiderable remimons, 
the urine depofits a lateritious fediment. This, 
however, does not prove entirely critical ; for 
the difeafe often continues long after fuch a 
icdiment has appeared in the urine. 

ececxLvn. 

When blood is drawn in this difeafe, it al- 
ways exhibits the appearance mentioned 
CCXXXVII. 

CCCCXLVTII, 

The acute rheumatifm, though it ha 
much of the nature of the other phlegmafia?,. 
differs from all thofe hitherto mentioned, in 
this, that rt is not apt to terminate in fuppura- 
i; on, This almoft never happens in rheuma- 

tifm ;, 



OF PHYSIC. 301 

tifm; but the difeafe fometimes produces ef- 
fufions of a tranfparent gelatinous fluid into 
the fheaths of the tendons. If we may be al- 
lowed to fuppofe that fuch effufions are fre- 
quent, it muft alfo happen, that the effufed 
fluid is commonly reabforbed ; for it has fel- 
dom happened, and never indeed to my ob- 
fervation, that confiderable or permanent tu- 
mours have been produced, or fuch as requir- 
ed to be opened, and to have the contained 
fluid evacuated. Such tumours, however,, 
have occurred to others, and the opening 
made in them has produced ulcers difficult to 
heal. Vide Storck. Ann. Med. II. 

CCCCXLIX. 

With the circumftances mentioned from 
CCCCXXXIX, to CCCCXLVIII, the dif- 
eafe often continues for feveral weeks. It 
feldom, however, proves fatal ; and it rarely 
happens that the pyrexia continues to be con- 
fiderable for more than two or three weeks. 
While the pyrexia abates in its violence,, if 
the pains of the joints continue, they are lefs- 
violent, more limited in their place, being 
confined commonly to one or a few joints on- 
ly, and are lefs ready to change their place. 

CCCCL. 

When the pyrexia attending rheumatifm 
entirely ceafed ; when the fwelling, and 

particularly 



302 PRACTICE 

particularly the rednefs of the joints, are en- 
tirely gone ; but when pains ftill continue to 
affect certain joints, which remain fliff, which 
feel uneafy upon motion, or upon changes of 
weather ; the difeafe is named the Chronic 
Rheumatifm, as it very often continues for a 
long time. As the chronic is commonly the 
fequel of the acute rheumatilm, I think it 
proper to treat of the former alto in this place. 

CCCCLI. 

The limits between the acute and chronic 
rheumatifm are not always exactly marked. 

When the pains are ilill ready tofhift their 
place ; when they are efpecially fevere in the 
night time ; when, at the fame time, they are 
attended with fome degree of pyrexia, and 
with fome fwelling, and efpecially with fome 
rednefs of the joints ; the difeafe is to be con- 
fidered as ftill partaking the nature of the.acute 
rheumatifm. 

But, when there is no degree of pyrexia re- 
maining ; when the pained joints are without 
rednefs ; when they are cold and fliff ; when 
they cannot eafily be made to fweat ; or when, 
while a free and warm fweat is brought out on 
the reft of the body, it is only clammy and 
cold on the pained joints ; and when, efpecial- 
ly the pains of thefe joints are increafed by 
cold, and relieved by heat applied to them ; 
the cafe is to be confidered as that of a purely 
chronic rheumatifm. CCC CLII. 



OF PHYSIC. 303 



CCCCLII. 

The chronic rheumatifm may affecl: differ- 
ent joints; but is efpecially ready to affecl: 
thofe joints which are furrounded with many 
mufcles, and thofe of which the mufcles are 
employed in the mod conflant and vigorous 
exertions. Such is the cafe of the vertebrae 
of the loins, the affettion of which is named 
Lumbago ; or that of the hip joint, when the 
difeafe is named Ifchias, or Sciatica. 

CCCCLIII. 

Violent {trains and fpafms occurring on 
fudden and fomewhat violent exertions, bring 
on rheumatic affections, which at firft partake 
of the acute, but very foon change into the 
nature of the chronic rheumatifm. 

CCCCLIV. 

I have thus delivered the hiftory of rheuma- 
tifm ; and fuppofe, that, from what has been 
faid, the remote caufes, the diagnofis, and 
prognofis, of the difeafe, may be underftood. 
The diftinftion of the rheumatic pains from 
thofe refembling them, which occur in the fy- 
philis and fcurvy, will be obvious, either from 
the feat of thofe pains, or from the concomi- 
tant fymptoms peculiar to thefe difeafes. The 
diftin&ion of rheumatifm from gout will 

be 



301 PRACTICE 

be more fully underftood from what is to bo 
delivered in the following chapter. 

CCCCLV. 

With refpecl; to the proximate caufc of 
rheumatifm, there have been various opinions. 
It has been imputed to a peculiar acrimony ; 
of which, however, in ordinary cafes, I can 
find no evidence ; and, from the confideratton 
of the remote caufes, the fymptoms, and cure 
of the difeafe, I think the fuppofition verv im- 
probable. 

The caufe of an Ifchias Nervoni aiiignedby 
Cotu n n i u s, appears tome hypothetical, and 
is not fupported by either the phenomena or 
method of cure. That, however, a difeafe of 
a rheumatic nature may be occafioned bv an 
acrid matter applied to the nerves, is evident 
from the toothach, a rheumatic afFe&ion gen- 
erally arifing from a carious toofh. 

That pains refembling thofe of rheumatifm,, 
may arife from deep feated fuppurations, we 
know from fome cafes depending on fuch a 
caufe, and which, m their fymptoms, refemble 
the lumbago or ifchias. I believe, however, 
that, by a proper attention, thefe cafes de- 
pending on fuppuration, may be commonly 
diftinguifhed from the genuine cafes of lum- 
bago and ifchias ; and, from what is fa id in 
CCCCXLVIII, I judge it to be at lead im- 
probable, that a genuine lumbago or ifchias 
does ever end in fuppuration. 

CCCCLVL. 



OF PHYSIC. 305 



CCCCLVI. 

The proximate caufe of rheumatifm has 
been by many fuppofed to be a lentor of the 
fluids obftru&ing the veffels of the part ; but 
the fame confideration as in CCXLI. 1, 2, 3, 
4, and 5, will apply equally here for rejecting 
the fuppofition of a lentor. 

CCCCLVII. 

While I cannot, therefore, find either evi- 
dence or reafon for fuppofing that the rheu- 
matifm depends upon any change in the ftate 
of the fluids, I muft conclude that the proxi- 
mate caufe of acute rheumatifm, is commonly 
the fame with that of other inflammations not 
depending upon a direct ftimulus. 

CCCCLVIII. 

In the cafe of rheumatifm I fuppofe, that 
the moll common remote caufe of it, that is, 
cold applied, operates efpecially on the veffels 
of the joints, from thefe being lefs covered by 
a cellular texture than thofe of the intermedi- 
ate parts of the limbs. I fuppofe further, 
that the application of cold produces a con- 
ftriftion of the extreme veffels on the furface, 
and at the fame time an increafe of tone or 
phlogifiic diathefis in the courfe of them,from 
which arifes an increafed impetus of the blood, 

and, 



306 PRACTICE 

and, at the fame time, a refiftance to the free 
paflage of it, and confequently inflammation 
and pain. Further, I fuppofe, that the re- 
fiftance formed excites the vis medicatrix to a 
further increafe of the impetus of the blood ; 
and, to fupport this, a cold ftage arifes, a fpafni 
is formed, and a pyrexia and phlogiflic dia- 
thefis are produced in the whole fyilem. 

CCCCLIX. 

According to this explanation, the caufe of 
acute rheumatifm appears to be exactly anal- 
ogous to that of the inflammations depending 
on an increafed afflux of blood to a part while 
it is expofed to the action of cold. 

But there feems to be alfo, in the cafe of 
rheumatifm, a peculiar affe&ion of the fibres 
of the mufcles. Thefe fibres feem to be un- 
der fome degree of rigidity, and therefore lefs 
eafily admit of motion ; and are pained upon 
the exertions of it. 

It is alfo an affe&ion of thefe fibres which 
gives an opportunity to the propagation of 
pains from one joint to another, along the 
courfe of the mufcles j and which pains are 
more feverely felt in the extremities of the 
mufcles terminating in the joints, becaufe be- 
yond thefe the ofcillations are not propagated. 

This affection of the mufcular fibres at- 
tending rheumatifm, feems to explain why 
drains and fpafms produce rheumatic affec- 
tions ; and, upon the whole, fhows, that, with 

an 



OF PHYSIC. 307 

an inflammatory affe&ion of the fanguiferous 
fyftem, there is alfo in rheumatifm a peculiar 
affe&ion of the mufcular fibres, which has a 
confiderable fhare in producing the phenome- 
na of the difeafe. 

CCCCLX. 

Having thus given my opinion of the 
proximate caufe of rheumatifm, I proceed to 
treat of the cure. 

CCCCLXI. 

Whatever difficulty may occur with refpecl 
to the explanation given (CCCCLVIII, and 
CCCCLIX) this remains certain, that in acute 
rheumatifm, at leafl; in all thofe cafes which 
do not arife from direct ftimuli, there is an 
inflammatory affection of the parts, and a 
phlogiftic diathefis in the whole fyflem ; and 
upon thefe is founded the method of cure, 
which frequent experience has approved of. 

CCCCLXII. 

The cure therefore requires, in the firft 
place, an antiphlogiftic regimen, and partic- 
ularly a total abftinence from animal food, 
and from all fermented or fpirituous liquors ; 
fubftituting a vegetable or milk diet, and the 
plentiful ufe of bland diluent drinks. 

CCCCLXIII, 



3 o8 PRACTICE 

CCCCLXIII. 

Upon the fame principle (CCCCL) at leaft 
with perhaps the fame exception as above, 
bloodletting is the chief remedy of acute rheu- 
matifm. The blood ought to be drawn in 
large quantity, and the bleeding is to be re- 
peated in proportion to the frequency, full- 
nefs, and hardnefs of the pulfe, and to the vi- 
olence of the pain. For the mod part, large 
and repeated bleedings, during the firfl chys 
of the difeafe, feem to be necefTary, and ac- 
cordingly have been very much employed ; but 
to this fome bounds are to be fet ; for very 
profufe bleedings occafion a flow recovery, 
and, if not absolutely effe&ual, are ready to 
produce a chronic rheumatifm. 

CCCCLXIV. 

To avoid that debility of the fyiictn, which 
general bleedings are ready to occafion, the ur- 
gent fymptom of pain may be often relieved 
by topical bleedings ; and, efpecially when 
any fwelling and rednefs have come upon a 
joint, the pain of it may be very certainly re- 
lieved by fuch bleedings ; but, as the contin- 
uance of the difeafe feems to depend more 
upon the phlogiftic diathefis of the whole fyf- 
tem, than upon the affe&ion of particular 
parts, fo topical bleedings will not always fup- 
ply the place of the general bleedings propof- 

ed above. 

CCCCLXV. 



OF PHYSIC. 309 



CCCCLXV. 

To take off the phlogiftic diathefis prevail- 
ing in this difeafe^ purging may be ufeful, if 
procured by medicines which do not ftimu- 
late the whole fyftem, fuch as the neutral falts, 
and which have in fome meafure a refrigerant 
power. Purging, however, is not fo powerful 
as bleeding, in removing phlogiftic diathefis ; 
and, when the difeafe has become general and 
violent, frequent ftools are inconvenient, and 
even hurtful, by the motion and pain which 
fhey occafion. 

CCCCLXVI. 

In acute rheumatifm, applications to the 
pained parts are of little fervice. Fomenta- 
tions, in the beginning of the difeafe, rather 
aggravate than relieve the pains. The ru- 
befacients and camphire are more effectual in 
relieving the pains ; but generally they only 
fhift the pain from one part into another, and 
do little towards the cure of the general affec- 
tion. Bliftering, applied to the pained part, 
may alio be very elfetlual in removing the 
pain from it ; but will be of little ufe, except 
where the pains arc much confined to one 
part. 

CCCCLXVII. 



3 io PRACTICE 



CCCCLXVII. 

The feveral remedies mentioned from 
(CCCCLI, to CCCCLV) moderate the vio- 
lence of the difeafe, and fometimes remove it 
entirely ; but they fometimes fail in this, and 
leave the cure imperfect. The attempting a 
cure by large and repeated bleedings, is at- 
tended with many inconveniences, (fee CXL); 
and the moft effectual and fafe method of cur- 
ing this difeafe, is, after fome general bleed- 
ings for taking off, or at lead diminifhing the 
phlogiftic diathefis, to employ fweating, con- 
duced by the rules laid down CLXVIII, 
and CLXIX. 

CCCCLXVIII. 

Opiates, except where they are directed to 
procure fweat, always prove hurtful in every 
flage of this difeafe. 

CCCCLXIX. 

The Peruvian bark has been fuppofed a 
remedy in fome cafes of this difeafe ; but we 
have feldom found it ufeful, and, in fome 
cafes, hurtful. It appears to me to be fit in 
thofe cafes only, in which the phlogiftic dia- 
thefis is already much abated ; and where at 
the fame time the exacerbations of the difeafe 

are 



O F P H Y S I C. 311 

are manifeflly periodical, withconfiderable re- 
miffions interpofc'd. 

CCCCLXX. 

Calomel, and fome other preparations of 
mercury, have been recommended in the 
acute rheumatifm ; but I believe they are ufe- 
ful only in cafes of the chronic kind, or at 
leafl in cafes approaching to the nature of 
thefe. 

CCCCLXXI. 

Having now treated fully of the cure of the 
r.cute rheumatifm, I proceed to treat of the 
cure of the chronic, which is fo frequently a 
fequel of the former. 

CCCCLXXII. 

The phenomena of the purely chronic 
rheumatifm, mentioned in CCCCXXXIX, 
and CCCCXL, lead me to conclude, that its 
proximate caufe is an atony, both of the 
blood vefTels and of the mufcular fibres of the 
part affected, together with a degree of rigidity 
and contradion in the latter, fuch as frequent- 
ly attends them in a ftate of atony. 

CCCCLXXIII. 

Upon this view of the proximate caufe, the 
general indication of cure mull be to reflore 

the 



312 



PRACTICE 



the activity and vigour of the vital principle in 
the part ; and the remedies for this difeale, 
which experience has approved of, are chiefly 
fuch as are manifeftly fuited to the indication 
propofed. 

CCCCLXXIV. 

Thefe remedies are either external or inter- 
nal. 

The external are, The fupporting the heat 
of the part, by keeping it conftantly covered 
with flannel ; the increafing the heat of the 
part by external heat, applied either in a dry or 
in a humid form ; the diligent ufe of the flefh 
brulh, or other means of friction ; the applica- 
tion of electricity in fparks or fhocks ; the ap- 
plication of cold water by affufion or immer- 
fion ; the application of effential oils of the 
mod warm and penetrating kind ; the ap- 
plication of fait brine ; and, laflly, the em- 
ployment of exercife, either of the part itfelf, 
fo far as it can eafily bear it ; or of the whole 
body, by riding, or other mode of geftation. 

CCCCLXXV. 

The internal remedies are, 1 . Large dofes 
of efTential oil drawn from refmous fubftances, 
fuch as turpentine ; 2. Subftances containing 
fuch oils, as guaiac ; 3. Volatile alkaline falts ; 
4. Thefe, or other medicines directed to pro- 
cure fweat, (CLXIX) ; and 3aRIy, Calomel, 

or 



OF PHYSIC. 313 

or other preparation of mercury, in fmall dof- 
es, continued for fome time. 

CCCCLXXVI. 

Thefe (CCCCLXIII, CCCCLXIV) are 

the remedies fuccefsfully employed in the 
purely chronic rheumatifm ; and there are 
ftill others recommended ; as bleeding, gen- 
eral and topical ; burning ; bliftering ; and 
iffues : But thefe appear to me to be chiefly, 
perhaps only, ufeful when the difeafe ftill par- 
takes of the nature of acute rheumatifm. 



O C H A P. 



314 PRACTICE 



CHAP. XIII. 



of the TOOTHACH or ODONTAL- 
GIA. 



CCCCLXXVII. 

I HAVE formerly confidered 
this difeafe as a fpecies of Rheumatifm, to be 
treated upon the fame principles as thofe de- 
livered in the preceding chapter ; but now, 
from more attentive confideration, I am led to 
confider the toothach as a diftincl; difeafe. 
Whilfl the mod of what has been delivered in 
the lad chapter proceeds upon the fuppofition 
that the rheumatifm depends upon a certain 
ftate of the blood veffels and of the motion of 
the blood in them, without this being produc- 
ed by the irritation of any acrid matter appli- 
ed ; I judge, that in $he toothach, though 
there are often the fame circum fiances in the 
ftate of the blood veffels as in the cafes of 
rheumatifm, thefe circumftances in toothach 
always arife from the application of an acrid 
matter to the nerves of the teeth. 



CCCCLXXVIII. 



OF PHYSIC. 315 



CCCCLXXVIII. ' 

This difeafe is often no other than a pain 
felt in a particular tooth, without any inflam- 
matory affection being at the fame time com- 
municated to the neighbouring parts. This, 
however, is rarely the cafe ; and for the mod 
part, together with the pain of the tooth, there 
is fome degree of pain and of inflammatory 
affection communicated to the neighbouring 
parts, fometimes to the whole of thofe on the 
fame fide of the head with the affected tooth. 

CCCCLXXIX. 

This inflammatory affection feems to me to 
be always an affection of mufcles and of the 
membranous parts connected with thefe, with- 
out any tendency to fuppuration ; and fuch an 
affection, as is excited by cold in fimilar parts 
elfewhere. It is from thefe circumftances 
that I conclude the affection to be of the rheu- 
matic kind. 

CCCCLXXX. 

It is poflible that the mufcles and mem- 
branes of the jaw may be affected by the 
fame caufes which produce the rheumatifm 
in other parts ; and it is alfo poflible, that a 
rheumatic diathefis at fir ft produced by irri- 
tation, may fubfift in the mufcles and mem- 
O 2 tranes 



316 PRACTICE 

branes of the jaw, fo that the inflammatory 
affection may be renewed by certain caufes 
without any new application of acrid matter : 
But I am periuaded that either of thele oc- 
currences are very rare, and I have never been 
able to afcertain any cafes of toothach to be of 
thefe kinds. I confider it, therefore, as high- 
ly probable that this rheumatic affection of 
the jaws which we name toothach, is always 
dependent upon fome immediate application 
of acrid matter to the nerves of the teeth. 



CCCCLXXXI. 

It is however to be obferved, that this ap- 
plication of acrid matter does not always ex- 
cite a pain in the tooth itfelf, or an inflamma- 
tory affection of the neighbouring parts ; but 
that it very often operates by producing a 
diathefis only ; fo that cold applied to the 
neighbouring parts does excite both a pain in 
the tooth, and an inflammatory affection of 
the neighbouring parts which did not appear 
before. 

There feems to be alfo certain ftates of the 
body, which operate upon the fame diathefis, 
fo as to produce toothach. Such feems to be 
the cafe of pregnant women, who are more li- 
able to toothach than other women. There 
are probably alfo. fome cafes of increafed irri- 
tability which render perfons more fubjecl: to 
toothach. Thus women are more liable to 

the 



OF PHYSIC. 317 

the difeafe than men, and particularly women 
liable to hyfierio affeaions. 

CCCCLXXXII. 

The acrid matter producing this difeafe 
feems to be generated firft in the hard fub- 
ftances of the teeth ; and as it often appears 
firft upon the external furface of thefe, it 
might be fufpected to arife from the applica- 
tion of external matters to the teeth : But as 
the production of this acrimony is often begun 
in the internal cavity of the teeth, where the 
operation of external matters cannot be fuf- 
pected, and as even when it begins upon the 
external parts of the teeth, the operation of the 
caufe is at firft in a fmall portion of the teeth 
only, that it is difficult to fuppofe that any 
matter externally applied could act in fuch a 
partial manner ; fo it is prefumed that the 
acrid matter occafioning the toothach is pro- 
duced by fome vice originating in the fub- 
ftance of the tooth itfelf. When it begins up- 
on the external furface, it is on the enamel ; but 
upon the internal furface, it mufl be in the bo- 
ny part. From what caufes it arifes in either 
of thefe fubflanccs, I do not at all know ; but' 
I fufpeci that it often arifes from fome more 
general fault in the fluids of the body. The 
frequent ufe oF mercury, efpecially when 
thrown much upon the mouth, and the flate 
of the fluids in lcurvy, feem both of them to 
give a difpofition to a caries in the teeth ; and 
O 3 {t 



3*3 PRACTICE 

it is poflible that fome other acrimonious dates 
of the fluids may have the fame effect. 

CCCCLXXXIII. 

A caries in fome part of the teeth, whether 
ariling upon their internal furface or upon 
their external, proceeding fo far as to reach 
the nerves in the cavity of the teeth, is pretty 
manifeftly the caufe of toothach, and of the 
firft attacks of it ; but when the cavity of the 
teeth has been opened, fo that the external 
air or other matters can reach that cavity, 
thefe are often the exciting caufes of toothach, 
and ferve to prove in general, that acrid mat- 
ters applied to the nerves occafion the difeafe. 

CCCCLXXXIV. 

What is the nature of the matter produced 
in the caries of the teeth, I do not underftand, 
nor have I found any proper corrector of it ; 
but I prefume it to be of the putrid kind, as it 
often taints the breath with a fetid odour. 

CCCCLXXXV. 

In the cure of this difeafe, a long experi- 
ence has fhown, that the extraction of the ca- 
rious tooth proves the moft effectual, and very 
often the only effectual, remedy of the dif- 
eafe. But as in fome cafes this extra 6lion is 
not proper, and as in many cafes it is obfti- 

nately 



OF PHYSIC. 319 

uately avoided, other means of curing the dif- 
eafe > or at leaft of relieving the pain, have 
been fought for and much praftifed. 

CCCCLXXXVI. 



Among thefe remedies, thofe are likely to 
be the molt effectual which entirely deftroy 
the affected nerve, or at lead fo much of it as 
is expofed to the aftion of the acrid matter in 
the tooth. When an opening is made into 
the cavity of the tooth, the nerve of it may be 
deftroyed raoft certainly by the actual caute- 
ry, and it may alio poflibly be done by the 
application of potential canities, either of the 
alkaline or acid kind. 

CCCCLXXXVII. 

When thefe remedies cannot be rendered 
effectual, relief may often be obtained by di- 
minifhing the fenfibility of the nerve affe&ed, 
by the application of opium, or of the more 
acrid aromatic oils, diredtly to the nerve in 
the tooth. It appears alfo, that the fenfibil- 
ity of the affe£ied nerve may often be for 
fome time diminifhed by the external appli- 
cation of opium to the extremities of thofe 
nerves in the (kin, which are branches of the 
fame fifth pair of nerves with thofe of the 
teeth. 

O 4 CCCCLXXXVIII. 



320 P K A (J 1 I C E 



CCCCLXXXVIII. 

When the difeafe confifts entirely in a pain 
of the nerve of the tooth, without any confid- 
erable affection communicated to the neigh- 
bouring parts, the remedies already mentioned 
are thofe efpecially to be employed ; but 
when the difeafe confifts very much in an in- 
flammatory affe&ion of the mufcles and mem- 
branes of the jaw, and when at the fame time 
there is little or no accefs for the abovemen- 
tioned remedies to the affected nerve, other 
meafures are to be employed for relieving the 
difeafe. 

CCCCLXXXIX. 

If the difeafe be attended with any general 
phlogiftic diathefis of the fyftem, or with any 
confiderable degree of pyrexia,a general bleed- 
ing may be ufeful in relieving the difeafe ; but 
thefe circumftances occur very rarely, and the 
difeafe is for the mod part a purely topical 
affection ; in which, as I obferved before, a 
general bleeding is of very little fervice. As 
this difeafe, however, is a topical inflammation, 
it might be fuppofed that topical bleedings 
would be very ufeful, and fometimes they are 
fo ; but it is feldom that their effects are ei- 
ther confiderable or permanent. The rea- 
fons of this I take to be, that the difeafe does 
not confift in an affection of the blood veffels 

alone. 









OF PHYSIC. 321 

alone, as in the ordinary cafes of rheumatifm ; 
but in a peculiar affe&ionof the fibres both of 
the mufcles and of the veflels of the part in- 
duced by irritation. The inefficacy of topical 
bleedings is with me a proof of the difeafe be- 
ing of the latter kind. 

ccccxc. 

The remedies therefore neceffary to give re- 
lief in this difeafe, are thofe which take off 
the fpafm of the veffels, and efpecially of the 
mufcles and membranes affected. Such are 
bliftering, brought as near to the part affetted 
as can be conveniently done ; and fuch are al- 
fo increafed excretions excited in the neigh- 
bouring parts, as of the faliva and mucus of 
the mouth by the ufe of acrid maflicatories. 
It is often fufficient to excite a flrong fenfa- 
tion in the neighbouring parts ; as by eau de 
luce, fpirit of lavender, or Hungary water 
fhuffed up the noftrils ; or by the vitriolic 
aether properly applied to the cheek. It is 
upon the fame footing that I fuppofe brandy 
or other ardent fpirit held in the mouth is oft- 
en of fervice. 

CCCCXCI. 

There are cafes of toothach in which it does 
not appear that the difeafe arifes from an ac- 
rid matter immediately applied to the nerve 
of a tooth ; but from the external application 
O 5 of 



322 PRACTICE 

of cold, or fome other caufes immediately ap- 
plied to the mufcles and membranes of the 
jaw ; and which therefore feem to require 
fome remedies different from thofe above- 
mentioned. But in all fuch cafes, it is to be 
fufpetted, that the erTe&s of cold or of other 
iuch caufes are owing to a diathefis produced 
hy an acrid matter applied to the nerve of a 
tooth, and continuing in fome meafure to a6l 
there ; and we have accordingly often found, 
that the a£tion of thofe external caufes were 
to be obviated only by the extraction of the 
tooth from which the diathefis had arifen. 



CHAP. 



OF PHYSIC. 323 

CHAP. XIV. 

OF THE GOUT. 



ccccxcir. 

1 H E Gout, not only as it 
occurs in different perfons, but even as it oc- 
curs in the fame perfon at different times, is 
a difeafe of fuch various appearance, that it is 
difficult to render the hiftory of it complete 
and exact, or to give a character of it that will 
univerfally apply. However, I fhall endeav- 
our to defcribe the difeafe as it moil common- 
ly appears, and to mark the varieties of it as 
well as I can. From fuch a hiftory I expeft 
that a general character may be given ; and 
fuch I think is the following, as given in the 
laft edition of our Nofology : 

Gen. XXIII. PODAGRA. 

Morbus haereditarius, oriens fine caufa ex- 
terna evidente, fed praeeunte plerumque ven- 
triculi affe&ione inlolita ; pyrexia ; dolor ad 
articulum et plerumque pedis pollici, certe 
pedum et manuum jun&uris, potiflimum in- 
c O6 fefius.; 



SH PRACTICE 

feftus ; per intervalla revertens, et faepe cum 
ventriculi et internarum partium affeclioni- 
bus alter nans. 

CCCCXCIII. 

The gout is generally a hereditary difeafe : 
But fome perfons, without hereditary difpofi- 
tion, feem to acquire it ; and, in fome, a hered- 
itary difpofition may be counteracted by va- 
rious caufes. Thefe circumftances may feem 
to give exceptions to our general pofition ; 
but the facls dire&ly fupporting it are very 
numerous. 

CCCCXCIV. 

This difeafe attacks efpecially the male fex ; 
but it fometimes, though more rarely, attacks 
alfo the female. The females liable to it are 
thofe of the more robuft and full habits ; and 
it very often happens to fuch long before the 
rnenitrual evacuation has ceafed. I have 
found it occurring in feveral females, whofe 
jnenftrual evacuations were more abundant 
than ufual. 

ccccxcv. 

This difeafe feldom attacks eunuchs ; and, 
when it does, they feem to be thofe who hap- 
pen to be of a robuft habit, to lead an indo- 
lent life, and to live very full. 

CCCCXCVI. 



OF PHYSIC. 325 

CCCCXCVI. 

The gout attacks efpecially men of robufl 
and large bodies, men of large heads, of full 
and corpulent habits, and men whofe fkins 
are covered with a thicker reie mucofum, which 
gives a coarfer furface. 

CCCCXCVII. 

If, with the ancients, we might afcertain, 
by certain terms, the temperaments of men, I 
would fay that the gout attacks efpecially men 
of a cholerico f anguine temperament, and that 
it very feldom attacks the purely fanguine or 
melancholic. It is, however, very difficult to 
treat this matter with due precifion. 

CCCCXCVIII. 

The gout feldom attacks perfons employed 
in conftant bodily labour, or perfons who live 
much upon vegetable aliment. It is alfo faid 
to be lets frequent among thofe people who 
make no ule of wine or other fermented 
liquors. 

CCCCXCIX. 

The gout does not commonly attack men, 
till after the age of five and thirty ; and gener- 
ally not till a flill later period. There are in- 
deed 



326 PRACTICE 

deed inflances of the gout occurring more ear- 
ly ; but thefe are few in comparifon of the 
numbers which agree with what we have given 
as the general rule. When the difeafe does 
appear early in life, it feems to be in thofe 
in whom the hereditary difpofition is very 
ftrong, and to whom the remote caufes to be 
hereafter mentioned have been applied in a. 
confiderable degree. 

D. 

As the gout is a hereditary difeafe, and af- 
fe6bs efpecially men of a particular habit, its 
remote caufes may be confidered as predifpo- 
nent and occalional. 



DL 



The predifponent caufe, fo far as exprefled 
by external appearances, or by the general 
temperament, we have already marked ; and 
phyficians have been very confident in aflign- 
ing the occalional caufes : But, in a difeafe 
depending fo much upon a predifpofition, the 
afligning occalional caufes muft be uncertain ;- 
as, in the predifpofed, the occalional caufes 
may not always appear, and in perfons not 
predifpofed, they may appear without efFecV 
This uncertainty mult particularly afFecl: the 
cafe of the gout ; but I mall offer what ap- 
pears to me moll probable on the fubjeft. 

D1L 



OF PHYSIC. 327 



DII. 

The occafional caufes of the gout feem to 
be of two kinds. Firft, thofe which induce a 
plethoric ftate of the body. Secondly, thofe 
which, in plethoric habits, induce a ftate of 
debility. 

Dili. 

Of the firft kind are a fedentary indolent 
manner of life, a full diet of animal food, and 
the large ufe of wine or of other fermented 
liquors. Thefe circumftances commonly pre- 
cede the difeafe ; and if there fhould be any 
doubt of their power of producing it, the 
facl:, however, will be rendered fufficiently 
probable by what has been obferved in 
CCCCXCVIII. 

DIV. 

Of the fecond kind of occafional caufes 
which induce debility are, excefs in venery j 
intemperance in the ufe of intoxicating liq- 
ours ; indigeftion, produced either by the 
quantity or quality of aliments ; much appli- 
cation to ftudy or bufinefs ; night watching ; 
exceflive evacuations ; theceafing of ufual la- 
bour ; the fudden change from a very full to 
a very fpare diet ; the large ufe of acids and 
acefcents ; and, laftly, cold applied to the 
lower extremities. DV. 



328 PRACTICE 



DV. 

The firft (Dili) feem to a& by increafmg 
the predifpofition. The laft (DIV) are com- 
monly the exciting caufes, both of the firft 
attacks, and of the repetitions of the difeafe. 

DVI. 

It is an inflammatory affection of fome of 
the joints which especially conftitutes what we 
call a paroxyfm of the gout. This fome times 
comes on fuddenly without any warning, but 
is generally preceded by feveral fymptoms. ^ 
fuch as the ceafing of a fweating which the 
feet had been commonly affefted with before -» 
an unufual coldnefs of the feet and legs ; a 
frequent numbnefs > alternating with a lenfe of 
prickling along the whole of the lower extrem- 
ities ; frequent cramps of the mufcles of the 
legs ; and an unufual turgefcence of the veins. 

DVII. 

While thefe fymptoms take place in the 
lower extremities, the whole body is affefted 
with fome degree of torpor and languor, and 
the functions of the ftomach in particular arG 
more or lefs difturbed. The appetite is di- 
minished ; and flatulency, or other fymptoms 
of indigeftion, are felt. Thefe fymptoms, and 
thofe of DVI, take place for feveral days r 

ibmetimes 



OF PHYSIC. 329 

fome times for a week or two, before a parox- 
yim comes on ; but commonly, upon the day 
immediately preceding it, the appetite be- 
comes greater than ufual. 

DVIII. 

The circumflances of paroxyfms are the 
following : They come on mofl commonly in 
the fpring, and fooner or later according as 
the vernal heat fucceeds fooner or later to the 
winter's cold ; and perhaps fooner or later alio 
according as the body may happen to be more 
or lefs expofed to viciflitudes of heat and cold. 

DIX. 

The attacks are fometimes felt firfl in the 
evening, but more commonly about two or 
three o'clock of the morning. The paroxyfm 
begins with a pain affecting one foot, moil 
commonly in the ball or firft joint of the great 
toe, but fometimes in other parts of the foot. 
With the coming on of this pain, there is com- 
monly more or lefs of a cold fhivering, which, 
as the pain increafes, gradually ceafes, and is 
fucceeded by a hot ftage of pyrexia, which 
continues for the fame time with the pain it- 
felf. From the firft attack, the pain becomes 
by degrees more violent, and continues in this 
ftate with great reftleffnefs of the whole body 
till next midnight, after which it gradually 
remits ; and, after it has continued for twenty 

four 



330 PRACTICE 

four hours from the commencement of the 
firft attack, it commonly ceafes very entirely, 
and, with the coming on of a gentle fweat, al- 
lows the patient to fall afleep. The patient, 
upon coming out of this fleep in the morning, 
finds the pained part affetted with fome red- 
nefs and fwelling, which, after having contin- 
ued forfome days, gradually abate. 

DX. 



When a paroxyfm has thus come on, al- 
though the violent pain after twenty four 
hours be confiderably abated, the patient is 
not entirely relieved from it. For fome days 
he has every evening a return of more confid- 
erable pain and pyrexia, and which continue 
with more or lefs violence till morning. Af- 
ter continuing in this manner for feveral days, 
the difeafe fometimes goes entirely off, not to 
return till after a long interval. 

DXI. 



When the difeafe, after having thus remain- 
ed for fome time in a joint, ceafes very entire- 
ly, it generally leaves the perfon in very per- 
fect health, enjoying greater eafe and alacrity 
in the functions of both body and mind, than 
he had for a long time before experienced. 

DXII. 



O F P H Y S I C. 331 



DXII. 

At the beginning of the difeafe, the returns 
of it are fometimes only once in three or four 
years ; but, after fome time, the intervals be- 
come fhorter, and the attacks become annual ; 
afterwards they come twice each year, and at 
length recur feveral times during the whole 
courfe of autumn, winter, and fpring ; and as 
it happens, that, when the fits are frequent, 
the paroxyfms become alfo longer, fo, in the 
advanced ftage of the difeafe, the patient is 
hardly ever tolerably free from it, except per- 
haps for two or three months in fummer. 

DXIII. 

The progrefs of the difeafe is alfo marked 
by the parts which it affects. At firft, it com- 
monly affe&s one foot«only, afterwards every 
paroxyfm affe&s both feet, the one after the 
other ; and, as the difeafe continues to recur, 
it not only affe£ts both feet at once, but after 
having ceafed in the foot which was fecondly 
attacked, returns again into the foot firft af- 
fected, and perhaps a fecond time alfo into the 
other. Its changes of place are not only from 
one foot to the other, but alfo from the feet 
into other joints, efpecially thofe of the upper 
and lower extremities ; fo that there is hardly 
a joint of the body that is not, on oneoccafion 
or other, affected. It fometimes affe6ls two 

different 



332 PRACTICE 

different joints at the fame time ; but more 
commonly it is fevere in a fmgle joint only, 
and panes fucceflively from one joint to an- 
other ; fo that the patient's affliction is often 
protracted for a long time. 

DXIV. 

When the difeafe has often returned, and 
the paroxyfms have become very frequent, 
the pains are commonly lefs violent than they 
were at firft ; but the patient is more affected 
with ficknefs, and the other fymptoms of the 
atonic gout, which fhall be hereafter men- 
tioned. 

DXV. 

After the firft paroxyfms of the difeafe, the 
joints which have been affected are entirely 
reftored to their former fupplenefs and 
ftrength ; but after the difeafe has recurred 
very often, the joints affected do neither fo 
fuddenly nor fo entirely recover their former 
ftate, but continue weak and ftiff ; and thefe 
effects at length proceed to fuch a degree, that 
the joints lofe their motion altogether. 

DXVI. 

In many perfons, but not in all, after the 
difeafe has frequently recurred, concretions of 
a chalky nature are formed upon the outfide 

of 



O F P H Y S I C. 333 

of the joints, and for the moft part immedi- 
ately under the fkin. The matter feems to 
be depofited at firft in a fluid form, but after- 
wards becomes dry and firm. In their dry 
ftate, thefe concretions are a friable earthy 
fubftance, very entirely lbluble in acids. Af- 
ter they have been formed, they contribute, 
with other circumftances, to deftroy the mo- 
tion of the joint. 

DXVII. 

In moft perfons who have laboured under 
the gout for many years, a nephritic affection 
comes on, and discovers itfelf by all the fymp- 
toms which ufually attend calculous concre- 
tions in the kidneys, and which we fhall have 
occafion to defcribe in another place. All that 
is neceffary to be obferved here is, that the 
nephritic affection alternates with paroxyfms 
of the gout ; and that the two affections, the 
nephritic and the gouty, are hardly ever pref- 
ent at the fame time. This alfo may be ob- 
ferved, that children of gouty or nephritic 
parents, commonly inherit one or other of 
thefe difeafes ; but which ever may have been 
the principal difeafe of the parent, fome of the 
children have the one, and fome the other* 
In fome of them, the nephritic affection oc- 
curs alone, without any gout fupervening; 
and this happens to be frequently the cafe of 
the female offspring of gouty parents. 

DXVIII. 



334 PRACTICE 

DXVIII. 

In the whole of the hiftory already given, 
I have defcribed the moft common form of 
the difeafe ; and which therefore, however di- 
verfified in the manner I have faid, may be 
ftill called the regular ftate of the gout. Up- 
on occafion, however, the difeafe afluines dif- 
ferent appearances ; but as I fuppofe the dif- 
eafe to depend always upon a certain diathefis 
or difpofition of the fyftem ; fo every appear- 
ance which we can pcrcieve to depend upon 
that fame difpofition, I ftill confider as a 
fymptom and cafe of the gout. The princi- 
pal circumftance in what we term the Regular 
Gouty is the inflammatory affection of the 
joints ; and whatever fymptoms we can per- 
ceive to be connected with, or to depend up- 
on, the difpofition which produces that in- 
flammatory affe&ion, but without its taking 
place, or being prefent at the fame time, we 
name the Irregular Gout. 

DXIX. 

Of fuch irregular gout there are three dif- 
ferent ftates ; which I name the atonic t the 
retrocedent, and the mi/placed gout. 

DXX. 

The atonic Mate is when the gouty diathe- 
fis prevails in the fyftem, but, from cer- 
tain 



OF PHYSIC. ^35 

tain caufes, does not produce the inflammato- 
ry affe6tion of the joints. In this cafe, the 
morbid fymptoms which appear are chiefly 
affections of the ftomach ; fuch as lofs of ap- 
petite, indigeftion, and its various circum- 
ftances of licknefs, naufea, vomiting, flatulen- 
cy, acid eructations, and pams in the region 
of the ftomach. Thefe fymptoms are fre- 
quently accompanied with pains and cramps 
in feveral parts of the trunk, and the upper 
extremities of the body, which are relieved by 
the difcharge of wind from the ftomach. To- 
gether witn thefe affections of the ftomach, 
there commonly occurs a coftivenefs ; but 
fometimes a loofenefs with colic pains. Thefe 
affections of the alimentary canal are often at- 
tended with all the fymptoms of hypochon- 
driafis ; as dejection of mind, a conftant and 
anxious attention to the flighteft feelings, an 
imaginary aggravation of thefe, and an appre- 
hension of danger from them. 

In the fame atonic gout, the vifcera of the 
thorax alfo are fometimes affected, and palpi- 
tations, faintings, and afthma, occur. 

In the head alfo occur, headachs, giddinefs, 
apoplectic and paralytic affections. 

DXXI. 

When the feveral fymptoms now mention- 
ed occur in habits having the marks of a gouty 
difpofition, this may be fufpected to have laid 
the foundation of them ; and efpecially when 

either. 



336 PRACTICE 

either, in fuch habits, a manifeft tendency to 
the inflammatory affection has formerly ap- 
peared ; or when the fymptomsp^r-rioned are 
intermixed with, and are not relieved by, fome 
degree of the inflammatory gout. In fuch 
cafes there can be no doubt of conlidering the 
whole as a ftate of the gout. 



DXXII. 



Another ftate of the difeafe I name the 
retrocedent gout. This occurs when an in- 
flammatory ftate of the joints has, in the ufual 
manner, come on, but which, without arifing 
to the ordinary degree of pain and inflamma- 
tion, or, at lead, without thefe continuing for 
the ufual time, and receding gradually in the 
ufual manner, they fuddenly and entirely 
ceafe, while fome internal part becomes af- 
fected. The internal part moft commonly 
affected is the ftomach, which is then affected 
with anxiety, ficknefs, vomiting, or violent 
pain ; but fometimes the internal part is the 
heart, which gives occafion to a fyncope ; 
fometimes it is the lungs which are affected 
with afthma ; and fometimes it is the head, 
giving occafion to apoplexy or palfy. In all 
thefe cafes, there can be no doubt of the fymp- 
toms being all a part of the fame difeafe, how- 
ever different the affection may feem to be in 
the parts which it attacks. 

Dxxur. 



OF PHYSIC. 337 



DXXIII. 

The third Hate of irregular gout, which we 
name the mifplaced, is when the gouty diathe- 
fis, iaftcad of producing the inflammatory af- 
fection of the joints, produces an inflammato- 
ry affe&ion of fome internal part, and which 
appears from the fame fymptoms that attend 
the inflammation of thofe parts arifing from 
other caufes. 

Whether the gouty diathefis does ever pro- 
duce fuch inflammation of the internal parts, 
without having firft produced it in the joints, 
or if the inflammation of the internal part be 
always a tranflation from the joints previ- 
ously affe&ed, I dare not determine ; but, even 
fuppofing the latter to be always the cafe, I 
think the difference of the affection of the in- 
ternal part muft ft ill diftinguifh the mif placed 
from what I have named the retrocedait gout. 

DXXIV. 

What internal parts may be affecled by 
the mifplaced gout, I cannot precifely fay, be- 
caufe I have never met with any cafes of the 
mifplaced gout in my practice ; and I find no 
cafes of it diftinftly marked by practical 
writers, except that of a pneumonic inflam- 
mation. 

P DXXV. 



33 8 PRACTICE 



DXXV. 

There are two cafes of a tranflated gout ; 
the one of which is an affection of the neck 
of the bladder, producing pain, flrangury, and 
a catarrhus veficae : The other is an affection 
of the rectum, fometimes by pain alone in that 
part, and fometimes by hemorrhoidal fwellings 
there. In gouty perfons, I have known fuch 
affections alternate with inflammatory affec- 
tions of the joints : But whether to refer thofe 
affections to the retrocedent, or to the mif- 
placed gout, I will not prefume to determine. 

DXXVI. 

From the hiflory which I have now deliver- 
ed of the gout, I think it may be difcerned 
under all its various appearances. It is, how- 
ever, commonly fuppofed, that there are cafes 
in which it may be difficult to diflinguiih gout 
from rheumatifm, and it is poffible there may 
be fuch cafes ; but, for the moil part, the two 
difeafes may be diftinguifhed with great cer- 
tainty by obferving the predifpofition, the an- 
tecedents, the parts affected, the recurrences 
of the difeafe, and its connexion with the 
other parts of the fyftem ; which circumitanc- 
es, for the moll part, appear very differently 
in the two difeafes. 

DXXVII. 






OF PHYSIC. 339 



DXXVII. 

With refpeft to the gout, our next bufinefs 
is to inveftigate its proximate caufe ; which 
muft be a difficult talk, and I attempt it with 
fome diffidence. 

DXXVIII. 

Upon this fubje6t, the opinion which has 
generally prevailed is, that the gout depends 
upon a certain morbific matter, always prefent 
in the body ; and that this matter, by certain 
caufes, thrown upon the joints or other parts, 
produces the feveral phenomena of the difeafe. 

DXXIX. 

This doctrine, however ancient and nener- 
al, appears to me very doubtful ; for, 

Firft, there is no direct evidence of any 
morbific matter being prefent in perfons dif- 
pofed to the gout. There are no experiments 
or obfervations which mow that the blood, 01 
other humours of gouty perfons, are in any 
refpecl; different from thofe of other perfons. 
Previous to attacks of the gout, there appear 
no marks of any morbid Irate of the fluids ; for 
the difeafe generally attacks thole perfons who 
have enjoyed the moil perfect health, and ap- 
pear to be in that Hate when the difeafe comes 
on. At a certain period of the difeafe, a pe- 
V 2 culiar 



340 PRACTICE 

culiar matter indeed appears in gouty perfons, 
(DXVI) ; but this, which does not appear in 
every inftance, and which appears only after 
the difeafe has lubiifted for a long time, feems 
manifeftly to be the effecl;, not the caufe, of 
the difeafe. Further, though there be certain 
acrids which, taken into the body, feem to ex- 
cite the gout (DIV), it is probable that thefe 
acrids operate otherwifc in exciting the difeafe, 
than by affording the material caufe of it. In 
general, therefore, there is no proof of any 
morbific matter being the caufe of the gout. 

Secondly, The fuppofitions concerning the 
particular nature of the matter producing the 
gout, have been fo various and fo contradic- 
tory to each other, as to allow us to conclude, 
that there is truly no proof of the exiflence of 
any of them. With rcfpecl; to many of thefe 
fuppofitions, they are fo inconfiftent with 
chemical philofophy, and with the laws of the 
animal economy, that they muft be entirely 
rejected. 

Thirdly, The fuppofition of a morbific 
matter being the caufe of the gout, is not con- 
fiflent with the phenomena of the difeafe, par- 
ticularly with its frequent and fudden tranfla- 
tions from one part to another. 

Fourthly, The fuppofition is further ren- 
dered improbable by this, that, if a morbific 
matter did exift, its operation mould be fimilar 
in the feveral parts which it attacks ; whereas 
it feems to be very different, being flimulant, 
and exciting inflammation in the joints, but 

fedative 



OF PHYSIC. 341 

fedative and deftroying the tone in the ftom- 
ach : Which, upon the fuppofition of partic- 
ular matter a&ing in both cafes, is not to be 
explained by any difference in the part af- 
fected. 

Fifthly, Some fafts, alleged in proof of a 
morbific matter, are not fufficiently confirm- 
ed, fuch as thole which would prove the dif- 
eafe to be contagious. There is, however, no 
proper evidence of this, the fadls given being 
not only few, but exceptionable ; and the 
negative obfervations are innumerable. 

Sixthly, Some arguments brought in fa- 
vour of a morbific matter, are founded upon 
a miftaken explanation. The difeafe has 
been fuppofed to depend upon a morbific 
matter, becaufe it is hereditary : But the in- 
ference is not jufl ; for moft hereditary dif- 
eafes do not depend upon any morbific mat- 
ter, but upon a particular conformation of the 
ftruclure of the body, tranfmitted from the 
parent to the offspring ; and this laft appears 
to be particularly the cafe in the gout. It 
may be aifo obferved, that hereditary difeafes, 
depending upon a morbific matter, alwavs ap- 
pear much more early in life than the gout 
commonly does. 

Seventhly, The fuppofition of a morbific 
matter being the caufe of the gout, has been 
hitherto ufelefs, as it has not fuggefted any 
fuccefsful method of cure. Particular fup- 
pofitions have often corrupted the practice, 
and have frequently led from thofe views 
p g which 



342 PRACTICE 

which might be ufeful, and from that practice 
which experience had approved. Further, 
though the fuppofition of a morbific matter 
has been generally received, it has been as 
generally neglected in practice. When the 
gout has affected the flomach, nobody thinks 
of correcting the matter fuppofed to be pref- 
ent there, but merely of reitoring the tone of 
the moving fibres. 

Eighthly, The fuppofition of a morbific 
matter is quite fuperfluous ; for it explains 
nothing, without fuppofing that matter to 
produce a change in the ftate of the moving 
powers ; and a change in the ftate of the mov- 
ing powers, produced by other caufes, ex- 
plains every circumflance, without the fup- 
pofition of a morbific matter ; and, to this 
purpofc, it may be obferved, that many of the 
caufes (DIV) exciting the gout, do not ope- 
rate upon the ftate of the fluids, but directly 
and folely upon that of the moving powers. 

Laftly, The fuppofition of a morbific mat- 
ter is alfo fuperfluous ; becaufe, without any 
fuch fuppofition, I think the difeafe can be 
explained in a manner more confiftent with 
its phenomena, with the laws of the animal 
economy, and with the method of cure which 
experience has approved. 

I now proceed to give this explanation; 
but, before entering upon it, I muft premife 
fome general obfervations. 



DXXX. 



OF PHYSIC. 343 



DXXX. 



The firft obfervation is, that the gout is a 
difeafe of the whole fyftem, or depends upon 
a certain general conformation and flate of 
the body ; which manifeflly appears from 
the facls mentioned from CCCCXCIV, to 
CCCCXCVII. But the general flate of the 
fyftem depends chiefly upon the flate of its 
primary moving powers ; and therefore the 
gout may be fuppofed to be chiefly an affec- 
tion of thefe. 

DXXXI. 

My fecond obfervation is, that the gout is 
manifeflly an affection of the nervous fyftem ; 
in which the primary moving powers of the 
whole fyftem are lodged. The occafional 
or exciting caufes (DIV) are almoft all 
fuch as a6l direftly upon the nerves and ner- 
vous fyftem ; and the greater part of the fymp- 
toms of the atonic or retrocedent gout are 
manifeflly affe6lions of the fame fyftem. 
(D'XX, and D XXI I.) This leads us to feek 
for an explanation of the whole of the difeafe 
in the laws of the nervous fyftem, and partic- 
ularly in the changes which may happen in the 
balance of its feveral parts. 

P 4 DXXXII. 



344 PRACTICE 



DXXXII. 

My third obfervation is, that the ftomach, 
which has fo univerfal a confent with the reft 
of the fyftem, is the internal part that is the 
moft frequently, and often very confiderably, 
affected by the gout. The paroxyfms of the 
difeafe are commonly preceded by an affec- 
tion of the ftomach (DVII) ; many of the ex- 
citing caufes (DIVJ acl; firft upon the ftom- 
ach ; and the fymptoms of the atonic and 
retrocedent gout (DXX, DXXII) are moft 
commonly and chiefly affections of the fame 
organ. This obfervation leads us to remark, 
that there is a balance fubfifting between the 
ftate of the internal and that of the external 
parts ; and, in particular, that the ftate of the 
ftomach is connected with that of the external 
parts, (XLIV) ; fo that the ftate of tone in 
the one may be communicated to the other. 

DXXXIII. 

Thefe obfervations being premifed, I fliali 
now offer the following pathology of the gout. 

In fome perfons, there is a certain vigorous 
and plethoric ftate of thefyftem(CCCCXCVI) 
which, at a certain period of life, is liable to a 
lofs of tone in the extremities (CCCCXCIX, 
DVI.) This is in fome meafure communi- 
cated to the whole fyftem, but appears more 
especially in the functions of the ftomach 

(DVII.) 



OF PHYSIC. 

(DVII.) When this lofs of tone occurs while 
the energy of the brain Hill retains its vigour, 
the vis medicatrix natural is excited to reftore 
the tone of the parts ; and accomplices it by 
exciting an inflammatory affection in fome 
part of the extremities. When this has fub- 
fifted for fome days, the tone of the extremi- 
ties, and of the whole fyflem, are reftored, and 
the patient returns to his ordinary ftate of 
health (DXl.) 

DXXXIV. 

This is the courfe of things, in the ordinary 
form of the difeafe, which we name the regu- 
lar gout ; but there are circumftances of the 
body, in which this courfe is interrupted or 
varied. Thus when the atony (DVI, DVIIJ 
has taken place, if the. reaction (DIXj do not 
fucceed, the atony continues in the ftomach, 
or perhaps in other internal parts, and pro- 
duces that ftate which we have, for reaions 
now obvious, named the atonic gout, . 

DXXXV. 

A fecond cafe of variation in the courfe of 
the gout is, when, to the atony, the reaction 
and inflammation have to a certain degree fuc- 
ceeded ; but, from caufes either internal or 
external, the tone of the extremities, and per- 
haps of the whole fyilem, is weakened ; fo 
that the inflammatory ftate, before it had ei- - 
P k thev 



346 PRACTICE 

ther proceeded to the degree, or continued 
for the time, requifite for reftoring the tone of 
the fyftem, fuddenly and entirely ceafes. 
Hence the ftomach, and other internal parts, 
relapfe into the ftate of atony ; and perhaps 
have this increafed by the atony communi- 
cated from the extremities : All which ap- 
pears in what we have termed the retrocedent 
gout. 

DXXXVI. 

A third cafe of variation from the ordinary 
courfe of the gout, is, when, to the atony ufu- 
ally preceding, an inflammatory reattion fully 
fucceeds ; but has its ufual determination to 
the joints by fome circumftances prevented ; 
and is therefore directed to an internal part, 
where it produces an inflammatory affe6tion, 
and that ftate of things which we have named 1 
the mif placed gout. 

DXXXVII. 

We have thus offered an explanation of the 
circumftances of the fyftem in the feveral ftates 
of the gout ; and this explanation we fuppofe 
to be confiftent with the phenomena of the 
difeafe, and with the laws of the animal econ- 
omy. There are indeed, with refpe6t to the 
theory of the difeafe, feveral queftions which 
might be put, to which we have not given any 
anfwer. But, though perhaps we could give 

an 



OF P H Y S-I C. 3i7 

an anfwer to many of thefe queftions, it does 
not here appear necenary ; as at prefcnt we 
intend only to eflablifh fuch general fads with 
regard to this difeafe, as may lay a foundation 
for the cure of it, fo far as experience has en- 
abled us to profecute it. Proceeding, there- 
fore, upon the feveral parts of the pathology 
given, as fo many matters of fact, I ihall now 
confider what may be attempted towards the 
cure of the difeafe. . 

DXXXVIII. 

In entering upon this, I mull obferve, in 
the firft place, that a cure has been commonly 
thought impoflible ; and we acknowledge it 
to be very probable, that the gout, as a difeafe 
of the whole habit, and very often depending 
upon original conformation, cannot be cured 
by medicines, the effecls of which are always 
very tranfitory, and feldom extend to the pro- 
ducing any coniiderable change of the whole 
habit. . 

DXXXIX. 

It would perhaps have been happy for 
gouty perfons, if this opinion had been im- 
plicitly received by them ; as it would have 
prevented their having been fo often the dupes 
of felfinterefted pretenders, who have either 
amufed them with inert medicines, or have 
rafhly employed thofe of the mod pernicious 
P 6 tendency. 



348 PRACTICE 

tendency. I am much difpofed to believe the 
impoflibility of a cure of the gout by medi- 
cines ; and more certainly ftill incline to think, 
that whatever may be the poffible power of 
medicines, yet no medicine for curing the 
gout has hitherto been found. Although al- 
moft every age has prefented a new remedy, 
yet all hitherto offered have very foon been 
either negle&ed as ufelefs, or condemned as 
pernicious. 

DXL. 

Though unwilling to admit the power of 
medicines, yet I contend, that a great deal 
can be done towards the cure of the gout by 
a regimen : And from what has been obferv- 
ed (CCCCXCVIII), I am firmly perfuaded, 
that any man who, early in life, will enter up- 
on the conftant practice of bodily labour, and 
of abftinence from animal food, will be pre- 
served entirely from the difeafe. 

Whether there be any other means of rad- 
ically curing the gout, I am not ready to de- 
termine. There are biftories of cafes of the 
gout, in which it is faid, that by great emo- 
tions of mind, by wounds, and by other acci- 
dents, the fymptoms have been fuddenly re- 
lieved, and never again returned ; but how 
far thefe accidental cures might be imitated by 
art, or would fucceed in other cafes, is at leaft 
extremely uncertain. 

DXLI. 



OK PHYSIC. 349 

DXLI. 

The practices proper and neceffary in the 
treatment of the gout, are to be confidered 
under two heads ; jirjl, As they are to be em- 
ployed in the intervals of paroxyfms ; or, 
fecondly t As during the time of thefe. 

DXLII. 

In the intervals of paroxyfms, the indica- 
tions are, to prevent the return of paroxyfms, 
or at leaft to render them lefs frequent, and 
more moderate. During the time of parox- 
yfms, the indications are, to moderate the vi- 
olence, and fhorten the duration of them as 
much as can be done with fafety. 

DXLIII. 

It has been already obferved, that the gout 
may be entirely prevented by conftant bodily 
exercife, and by a low diet ; and I am of opin- 
ion, that this prevention may take place even 
in perfons who have a hereditary difpofition 
to the difeafe. I muft add here, that, even 
when the difpofition has difcovered itfelf by 
feveral paroxyfms of inflammatory gout, I am 
perfuaded that labour and abftinence will ab- 
solutely prevent any returns of it for the reft 
of life. Thefe, therefore, are the means of 
anfwering the firft indication to be purfued in 

the 



350 P'RACTICa 

the intervals of paroxyfms ; and I mud here 
offer fome remarks upon the proper ule of 
thefe remedies. 

DXLIV. 

Exercife, in perfons difpofed to the gout, is 
directed to two purpofes : One of thefe is the 
ftrengthening of the tone of the extreme vel- 
fels ; and the other, the guarding againft a 
plethoric flate. For the former, if exercife 
be employed early in life, and before intem- 
perance has weakened the body, a very mod-i 
erate degree of it will anfwer the purpofe ; 
and for the latter, if abflinence be at the fame 
time obferved, little exercife will beneceffary. 

DXLV. 

With refpe6t to exercife, this in general is 
to be obferved, that it fhould never be violent ; 
for, if violent, it cannot be long continued, 
and muft always endanger the bringing on an 
atony in proportion to the violence of the 
preceding exercife. 

DXLVI. 

It is alfo to be obferved, that the exercife 
of geftation, though confiderable and conftant, 
if it be entirely without bodily exercife, will 
not anfwer the purpofe in preventing the gout. 
For this end, therefore, the exercife muft be 

in 



OF PHYSIC. 351 

in fomc meafure that of the body; and rauft 
be moderate, but at the fame time conftant, 
and continued through life. 

DXLVII. 

In every cafe and circumftance of the gout 
in which the patient retains the ufe of his 
limbs, bodily exercife, in the intervals of par- 
oxyfms, will always be ufeful ; and, in the be- 
ginning of the difeafe, when the difpofition 
to it is not yet ftrong, exercife may prevent a 
paroxyfm which otherwife might have come 
on. In more advanced ftates of the difeafe, 
however, when there is fome difpofition to a 
paroxyfm, much walking will bring it on ; ei- 
ther as it weakens the tone of the lower ex- 
tremities, or as it excites an inflammatory dif- 
pofition in them ; and it is probable, that in 
the fame manner drains or contufions often 
bring on a paroxyfm of the gout. 

DXLVIII. 

Abflinence, the other part of our regimen 
(DXL) for preventing the gout, is of more 
difficult application. If an abflinence from 
animal food be entered upon early in life, 
while the vigour of the fyftem is yet entire, 
we have no doubt of its being both fafe and 
effectual ; but if the motive for this diet fhall 
not have occurred till the conftitution fhall 
have been broken by intemperance, or by the 

decline 



352 P R A C T I C E 

decline of life, a low diet may then endanger 
the bringing on an atonic ftate. 

DXLIX. 

Further, if a low diet be entered upon only 
in the decline of life, and be at the lame time 
a very great change in the former manner of 
living, the withdrawing of an accuflomed 
flimulus of the fyftem may readily throw this 
into an atonic ftate. 

DL. 

The fafety of an abftemious courfe may be 
greater or lefs according to the management 
of it. It is animal food which efpecially dif- 
pofes to the plethoric and inflammatory ftate, 
and that food is. to be therefore efpecially a- 
voided ; but, on the other hand, it is vegetable 
aliment of the loweft quality that is in danger 
of weakening the fyftem too much, by not af- 
fording fufficient nourifhment ; and more par- 
ticularly of weakening the tone of the ftomach 
by its acefcency. It is therefore a diet of a 
middle nature that is to be chofen • and milk 
is precifely of this kind, as containing both an- 
imal and vegetable matter. 

As approaching to the nature- of milk, and 
as being a vegetable matter containing the 
greateft portion of nourifhment, the farinace- 
ous feeds are next to be chofen, and are the 
food moft proper to be joined with milk. 

DLL 



O F P H Y S I C. 353 



DLL 

With refpecT: to drink, fermented liquors 
are ufeful only when they are joined with an- 
imal food, and that by their acefcency ; and 
their flimulus is only necefTary from cuftora. 
When, therefore, animal food is to be avoid- 
ed, fermented liquors are unneceflfary ; and, by 
increafing the acefcency of vegetables, thefe 
liquors may be hurtful. The flimulus of fer- 
mented or fpirituous liquors, is not necefTary 
to the young and vigorous ; and, when much 
employed, impairs the tone of the fyftem. 
Thefe liquors, therefore, are to be avoided, 
except fo far as cuflom and the declining ftate 
of the fyftem may have rendered them necef- 
fary. For preventing or moderating the reg- 
ular gout, water is the only proper drink. 

DLII. 

With refpec~l to an abftemious courfe, it 
has been fuppofed, that an abflinence from an- 
imal food and fermented liquors, or the living 
upon milk and farinacea alone for the fpace 
of one year, might be fufficient for a radical 
cure of the gout ; and it is poflible, that, at a 
certain period of life, in certain circumftances 
of the conftituion, fuch a meafure might an- 
fwer the purpofe. But this is very doubtful ; 
and it is more probable that the abflinence 
mud, in a great meafure, be continued, and 

the 



354 PRACTICE 

the milk diet be perfifted in, for the reft of 
life. It is well known, that feveral pcrfons 
who had entered on an abftemious courfe, and 
had been thereby delivered from the gout, have, 
however, upon returning to their tormcr man- 
ner of full living, had the difeafe return upon 
them with as much violence as before, or in a 
more irregular and more daiigerous form.. 

DLIII. 

It has been alleged, that, for preventing 
the return of the gout, bloodletting, or fcari- 
fications of the ieet, frequently repeated, and 
at dated times, may be practiied with advan- 
tage j but of this I have had no experience. 

DLIV. 

Exercife and abftinence are the means of 
avoiding the plethoric ftate which gives the 
difpofition to the gout ; and are therefore the 
means propofed for preventing paroxyfms, or 
at lead for rendering them lefs frequent, and 
more moderate. But many circumftances 
prevent the fteadinefs neceflary in purfuing 
thefe meafures ; and therefore, in fuch cafes, 
unlefs great care be taken to avoid the exciting 
caufes, the difeafe may frequently return ; 
and, in many cafes, the preventing of parox- 
yfms is chiefly to be obtained by avoiding thofe 
exciting caufes enumerated in DIV. The 
conduct neceffary for avoiding them, will be 

fufliciently 



OF PHYSIC. 355 

fufficiently obvious to perfons acquainted with 
the doctrines of the Hygieine, which I fup- 
poic to have been delivered in another place. 

ULV. 

A due attention in avoiding thofe feveral 
caufes (Dili, DIV) will certainly prevent fits 
of the gout ; and the taking care that the ex- 
citing caufes be never applied in a great de- 
gree, will certainly render fits more moderate 
when they do come on. But, upon the whole, 
it will appear, that a ftricT: attention to the 
whole conduct: of life, is in this matter necef- 
fary ; and therefore, when the predifpofition 
has taken place, it will be extremely difficult 
to avoid the difeafe. 

DLVI. 

I am indeed firmly perfuaded, that, by ob- 
viating the predifpofition, and by avoiding the 
exciting caufes, the gout may be entirely pre- 
vented : But as the meafures neceffary for 
this purpofe will, in moft cafes, be purfued 
with difficulty, and even with reluctance, men 
have been very defirous to find a medicine 
which might anfwer the purpofe without any 
reftraint on their manner of living. To grat- 
ify this defire, phyficians have propofed, and, 
to take advantage of it, empirics have feigned, 
many remedies, as we have already obferved. 
Of what nature feveral of thefe remedies have 

been, 



356 PRACTICE 

been, I cannot certainly fay ; but, of thofe 
which are unknown, we conclude, from their 
having been only of temporary fame, and from 
their having foon fallen into neglect, that they 
have been either inert or pernicious, and there- 
fore I make no inquiry after them ; and mall 
now remark only upon one or two known 
remedies for the gout which have been lately 
in vogue. 



DLVII. 



One of thefe is what has been named in 
England the Portland Powder. This is not a 
new medicine, but is mentioned by Galen, 
and, with fome little variation in its compofi- 
tion, has been mentioned by the writers of al- 
moft every age fince that time. It appears to 
have been at times in fafhion, and to have a- 
gain fallen into negle6t ; and I think that this 
laft has been owing to its having been found 
to be, in many inftances, pernicious. In ev- 
ery inftance which I have known of its exhibi- 
tion for the length of time prefcribed, the per- 
fons who had taken it were indeed afterwards 
free from any inflammatory affection of the 
joints ; but they were affected with many 
fymptoms of the atonic gout ; and all, foon 
after finifhing their courfe of the medicine, 
have been attacked with apoplexy, aflhma, or 
dropfv, which proved fatal. 

DLVIII. 



OF PHYSIC. 357 

DLVIII. 

Another remedy which has had the appear- 
ance of preventing the gout, is an alkali in va- 
rious forms, fuch as the fixed alkali both mild 
and cauftic, lime water, foap, and abforbent 
earths. Since it became common to exhibit 
thefe medicines in nephritic and calculous 
cafes, it has often happened that they were 
given to thofe who were at the fame time fub- 
jett to the gout ; and it has been obferved, 
that, under the ufe of thefe medicines, gouty 
perfons have been longer free from the fits of 
their difeafe. That, however, the ufe of thefe 
medicines has entirely prevented the returns 
of gout, I do not know ; becaufe I never pufh- 
ed the ufe of thofe medicines for a long time, 
being apprehenfive that the long continued 
ufe of them might produce a hurtful change 
in the ftate of the fluids. 

DUX. 

With refpe£t to preventing the gout, I have 
only one other remark to offer. As the pre- 
venting the gout depends very much on Sup- 
porting the tone of the ftomach, and avoiding 
indigeftion; fo coftivenefs, by occafioning this, 
is very hurtful to gouty perfons. It is there- 
fore neceffary for fuch perfons to prevent or 
remove coftivenefs, and by a laxative medicine, 
when needful ; but it is at the fame time prop- 
er, 



358 PRACTICE 

er, that the medicine employed mould be fuch 
as may keep the belly regular, without much 
purging. Aloetics, rhubarb, magnefia alba, 
or flowers of fulphur, may be employed, as 
the one or the other may happen to be belt 
fuited to particular perfons. 



DLX. 

Thefe are the feveral meafures (from 
DXLII, to DLIX) to be purfued in the in- 
tervals of the paroxyfms ; and we are next to 
mention the meafures proper during the time 
of them. 



DLXI. 

As during the times of paroxyfms the body 
is in a feverifh date, no irritation fhould then 
be added to it ; and every part, therefore, 
of the antiphlogiftic regimen, (CXXX, to 
CXXXIII) except the application of cold, 
ought to be ftriclly obferved. 

Another exception to the general rule may 
occur when the tone of the flomach is weak, 
and when the patient has been before much 
accuftomed to the ufe of ftrong drink ; for then 
it may be allowable, and even neceffary, to 
give fome animal food, and a little wine. 

DLXIL 



OF PHYSIC. 359 



DLXII. 



That no irritation is to be added to the fyf- 
tem during the paroxyfms of gout, except in 
the cafes mentioned, is entirely agreed upon 
among phyficians : But it is a more difficult 
matter to determine whether, during the time 
of paroxyfms, any meafures may be purfued 
to moderate the violence of reaction and of 
inflammation. Dr. Sydenham has given it as 
his opinion, that the more violent the inflam- 
mation and pain, the paroxyfms will be the 
fhorter, as well as the interval between the 
prefent and next paroxyfm longer ; and, if 
this opinion be admitted as juft, it will forbid 
the ufe of any remedies which might mode- 
rate the inflammation ; which is, to a certain 
degree, undoubtedly neceflary for the health of 
the body. On the other hand, acute pain 
prefles for relief ; and, although a certain de- 
gree of inflammation may feem abfolutely 
neceflary, it is not certain but that a moderate 
degree of it may anfwer the purpofe : And it 
is even probable, that, in many cafes, the vio- 
lence of inflammation may weaken the tone 
of the parts, and thereby invite a return of 
paroxyfms. It feems tome to be in this way, 
that, as the difeafe advances, the paroxyfms 
become more frequent. 

DLXIII. 



360 PRACTICE 



DLXIII. 

From thefe laft confi derations, it feems 
probable, that, during the time of paroxyfms, 
fome meafures may be taken to moderate the 
violence of the inflammation and pain ; and 
particularly, that in firft paroxyfms, and in the 
young and vigorous, bloodletting at the arm 
may be pract.ifed with advantage : But I am 
perfuaded, that this practice cannot be re- 
peated often with fafety ; becaufe bloodletting 
not only weakens the tone of the fyftem, but 
may alfo contribute to produce plethora. I 
believe, however, that bleeding by leeches on 
the foot, and upon the inflamed part, may be 
pra&ifed, and repeated with greater fafety ; 
and I have known inftances of its having been 
pra&ifed with fafety, to moderate and fhorten 
paroxyfms ; but how far it may be carried, we 
have not had experience enough to deter- 
mine. 

DLXIV. 

Befides bloodletting, and the antiphlo- 
giftic regimen, it has been propofed to employ 
remedies for moderating the inflammatory 
fpafm of the part a Hefted, fuch as warm bath- 
ing and emollient poultices. Thefe have 
fometimes been employed with advantage and 
fafety ; but at other times, have been found to 
give occafion to a retrocefllon of the gout. 

DLXV. 



O F P II Y S I C. 3.61 



DLXV. 

Bliftering is a very effectual means of re- 
lieving and difcufling a paroxyfm of the gout ; 
but has alfo frequently had the effect of ren- 
dering it retrocedent. 

DLXVI. 

The flinging with nettles I confider as 
analogous to bliftering; and I think it proba- 
ble that it would be attended with the fame 
danger. 

DLXVII. 

The burning with moxa, or other fub- 
flances, I confider as a remedy of the fame 
kind. I have had indeed no evidence of this 
proving hurtful ; but neither have I had any 
proper evidence of its having proved a radi- 
cal cure. 

DLXVIII. 

Camphire, and fome aromatic oils, have 
the power of allaying the pain, and of re- 
moving the inflammation from the part af- 
fected ; but thefe remedies commonly make 
the inflammation only fhift from one part to 
another, and therefore with the hazard of its 
falling upon a part where it may be more 
Q dangerous ; 



362 PRACTICE 







dangerous ; and they have fometimes render- 
ed the gout retiocedent. 

DLXIX. 

From thefe reflections (DLXIV. et feq.) it 
will appear, that fome danger muft attend ev- 
ery external application to the parts affected 
during a paroxyfm j and that therefore the 
common prafticc of committing the perfon to 
patience and flannel alone, is eflabliihed up- 
on the bed foundation. 

DLXX. 

Opiates give the molt certain relief from 
pain ; but, when given in the beginning of 
gouty paroxyfms, occafion thefe to return with 
greater violence. When, however, the par- 
oxyfms mail have abated in their violence, but 
ftill continue to return, fo as to occafion pain- 
ful and reitlefs nights, opiates may be then 
given with fafety and advantage, efpecially in 
the cafe of perfons advanced in life, and who 
have been often affected with the difeafe. 

DLXXI. 

When, after paroxyfms have ceafed, fome 
fwelling and ftiffnefs (hall remain in the joints, 
thefe fymptoms are to be difcuffed by the dili- 
gent ule of the flefh brum. 

DLXXII. 



OF PHYSIC. 3 6 3 

DLXXII. 

Purging, immediately after a paroxyfm, 
will be always employed with the hazard of 
bringing it on again. 

DLXXIII. 

I have now finifhed what has occurred to 
be faid upon the means of preventing and cur- 
ing the regular gout ; and fhall now confider 
its management when it has become irregular ; 
of which, as I have obferved above, there are 
three different cafes. 

DLXXIV. 

In the firft cafe, which I have named the 
Atonic Gout, the cure is to be accomplifhed 
by carefully avoiding all debilitating caufes ; 
and by employing, at the fame time, the 
means of ftrengthening the lyttem in general, 
and the ftomach in particular. 

DLXXV. 

For the avoiding debilitating caufes, I muft 
refer to the do&rines of the Hygieine, as in 
DLIV. 

DLXXVI. 



364 I > R A C T I C E 



DLXXVI. 

For flrengthening the fyflem in gener- 
al, I muft recommend frequent exercife on 
horfeback, and moderate walking. Cold bath- 
ing alfo may anfwer the purpofe, and may- 
be fafely employed, if it appear to be power- 
ful in flimulating the fyftem, and be not ap- 
plied when the extremities are threatened with 
any pain. 

For fupporting the tone of the fyftem in 
general, when threatened with atonic gout, 
iome animal food ought to be employed, and 
the more acefcent vegetables ought to be a- 
voided. In the fame cafe, fome wine alfo 
may be neceffary ; but it fhould be in mode- 
rate quantity, and of the leait acefcent kinds ; 
and if every kind of wine fhall be found to 
increafe the acidity of the flomach, ardent 
fpirits and water muft be employed. 

DLXXVII. 

For flrengthening the flomach, bitters and 
the Peruvian bark may be employed ; but care 
muft be taken that they be not conftantly em- 
ployed for any great length of time. Com- 
pare DLVII. 

The mod effectual medicine for flrengthen- 
ing the flomach is iron, which may be em- 
ployed under various preparations ; but, to 
me, the befl appears to be the ruft in fine 

powder, 



O F P H Y S I C. 3 6 5 

powder, which may be given in very large 
dofes. 

For fupporting the tone of the ftornach, ar- 
omatics may be employed ; but fhouid be ufcd 
with caution, as the frequent and large ule of 
them may have an oppofite effe£t ; and they 
fhouid therefore be given only in compliance 
with former habits, or for palliating prefent 
fymptoms. 

When the ftomach happens to be liable to 
indigeftion, gentle vomits may be frequently 
given ; and proper laxatives fhouid be always 
employed to obviate, or to remove, coftive- 
nefs. 

DLXXVIII. 

In the atonic gout, or in perfons liable to 
it, to guard againfl cold is efpecially neceffa- 
ry ; and the moft certain means of doing this, 
is, by repairing to a warm climate during the 
winter feafon. 

DLXXIX. 

In the more violent cafes of the atonic gout, 
bliftering the lower extremities may be ufeful ; 
but that remedy mould be avoided when any 
pain threatens the extremities. In perfons 
liable to the atonic gout, illues may be eftab- 
liftied in the extremities, as, in fome mealure, 
a fupplement to the difeafe. 

DLXXX. 



366 PRACTICE 



DLXXX. 

A fecond cafe of the irregular gout, is that 
which I have named the Retrocedent. When 
this affects the ftomach and interlines, relief 
is to be inftantly attempted by the free ufe 
of ftrong wines, joined with aromatics, and 
given warm ; or if thefe (hall not prove power- 
ful enough, ardent fpirits muft be employed, 
and are to be given in a large dofe. In mod- 
erate attacks, ardent fpirits impregnated with 
garlic, or with afafcetida, may be employed ; 
or, even without the ardent fpirits, a folution 
of afafcetida with the volatile alkali may an- 
fwer the purpofe. Opiates are often an ef- 
fectual remedy, and may be joined with aro- 
matics, as in the Ele&uarium Thebaicum ; or 
they may be ufefully joined with volatile al- 
kali and camphire. Mulk has likewife prov- 
ed ufeful in this difeafe. 

When the affection of the ftomach is ac- 
companied with vomiting, this may be en- 
couraged, by taking draughts of warm wine, 
at firlt with water, and afterwards without 
it ; having at length recourfe, if neceffary, to 
fome of the remedies above mentioned, and 
particularly the opiates. 

In like manner, if the inteflines be affected 
with diarrhoea, this is to be at firft encouraged, 
by taking plentifully of weak broth ; and when 
this mail have been done fufficiently, the tu- 
mult is to be quieted by opiates. 

DLXXXI. 



OF PHYSIC. 367 



BLXXXI. 

When the retrocedent gout fhall affecT; the 
ungs, and produce afthma, this is to be cured 
oy opiates, by antifpafmodics, and, perhaps, 
)y bliflering on the breafl or back. 

DLXXXII. 

When the gout, leaving the extremities, 
ihall afFecl: the head, and produce pain, verti- 
go, apoplexy, or pal/y, our refources are very 
precarious. The mod probable means of re- 

ief is, bliflering the head ; and if the gout 
(hall have receded very entirely from the ex- 
tremities, blifters may be applied to thefe al- 
io. Together with thefe blifterings, arorriat- 

cs, and the volatile alkali, may be thrown in- 

.0 the flomach. 

DLXXXIII. 

The third cafe of the irregular gout is what 
[ have named the Mifplaced ; that is, when 
he inflammatory affection of the gout, inftead 
of falling upon the extremities, falls upon fome 
internal part. In this cafe, the difeafe is to be 
:reated by bloodletting, and by fuch other 
remedies as would be proper in an idiopathic 
inflammation, of the fame parts. 

DLXXX1V. 



368 P R A C T I C E, &c. 

DLXXXIV. 

Whether the tranflation fo frequently made 
from the extremities to the kidneys, is to be 
confidered as an inftance of the mifplaced 
gout, feems, as we have laid before, uncertain ; 
but I am difpofed to think it fomething differ- 
ent ; and therefore am of opinion, that, in the 
Nephralgia Calculofa produced upon this oc- 
calion, the remedies of inflammation are to be 
employed no farther than they may be other- 
wile fbmetimes neceflary in that difeafe, arif- 
ing from other caufes than the gout. 



f 



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